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LIPPINCOTT^S 
NURSING  MANUALS 


ESSENTIALS  OF  SURGERY 

BY 

ARCHIBALD  L.  McDONALD,  M.D. 


LIPPINCOTT'S 

NURSING    MANUALS 

FULL  CATALOGUE  FREE  ON  REQUEST 

Ninth  Edition  Revised 

COOKE'S  HANDBOOK   OF  OBSTETRICS 

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of  City  Hospital,  New  York.  475  pages.  188  illlustrations.  Ja.as  net 

CARE  AND  FEEDING 
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A  TEXT-BOOK  FOR  TRAINED  NURSES 
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ESSENTIALS  OF  MEDICINE   Third  Edition 

By   CHARLES  PHILLIPS  EMERSON,   M.D.,   of  University  of 
Indiana.    401  pages.     117  illustrations.    I2.S0  net. 

Second  Edition  Revised 

PHYSICS  AND  CHEMISTRY  FOR  NURSES 

By  A.  R.  BLISS,  M.D.,  Grady  Hospital,  Atlanta,  Ga.,  and  A.  11. 

OLIVE,   A.B.,    Ph.D.,   Hillman   Hospital,   Birmingham. 

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NURSING  AND  CARE      Third  Edition 
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143  pages.    12  illustrations,     fi.50  net. 

HOW    TO    COOK  Fifth  Edition 

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Journal  of  Nursing.     244  pages.    ?l.7S  net. 


LIPPINCOTT'S  NURSING  MANUALS 


ESSENTIALS  OF  SURGERY 


A  TEXTBOOK  OF  SURGERY 

FOR  STUDENT  AND  GRADUATE  NURSES  AND  FOR 
THOSE   INTERESTED   IN  THE   CARE  OF  THE   SICK 


BY 

ARCHIBALD  LEETE  McDONALD,  M.D. 

THE  JOHNS  HOPKINS  UNIVERSITY. 

FORMERLY   IN   CHARGE    OF   DEPARTMENT    OF  ANATOMY,    UNIVERSITY    OF     NORTH    DAKOTA; 

LECTURER  ON  SURGERY,    NURSES  TRAINING  SCHOOL,   ST.   LUKES  HOSPITAL, 

DULUTH,   MINNESOTA 


46  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


COPYRIGHT,    I919.   BY  J.   B.   LIPPINCOTT  COMPANY 


H.M    .'vU^e>^   o^^VVfiA 


Electrotyfed  and  printed  by  J.  B.  Lippincoti  Company 
The  Washington  Square  Press,  Philadelphia,  U.  S.  A. 


TO 

MY  WIFE 
GRACE    MOREHOUS    McDONALD 

MY  MOST  EXACTING  AND  DEVOTED  CRITIC 


PREFACE 

These  notes  are  prepared  for  the  use  of  senior  nurses  in 
connection  with  a  course  on  "The  Principles  of  Surgery,"  in 
the  beUef  that  the  nurse  can  more  intelligently  assist  in  the 
care  of  her  patient  if  she  has  a  reasonable  conception  of  the 
conditions  present  and  of  the  indications  to  be  met  in  treat- 
ment. An  elementary  understanding  of  anatomy,  physiology, 
and  bacteriology,  as  usually  presented  to  nurses,  is  assumed. 
No  attempt  is  made  to  cover  these  subjects,  except  in  a  few 
instances  to  emphasize  certain  relations  to  surgical  conditions. 

The  course  covers  the  general  principles  of  surgical  diseases 
and  the  pathological  changes  which  result.  Also,  under  separate 
headings,  the  more  important  surgical  lesions  involving  special 
regions  of  the  body,  are  considered.  The  matter  is  presented 
simply,  and  only  general  statements  are  made  concerning: 

1.  Etiology,  causal  factors. 

2.  Pathology,  local  tissue  changes  produced,  and  general 
effects. 

3.  Natural  course  of  the  disease  and  spontaneous  attempts 
to  control  the  condition,  also  factors  influencing  the  prognosis. 

4.  Indications  for  treatment,  and  the  general  principles 
which  are  to  be  considered.  No  attempt  is  made  to  dis- 
cuss technical  nursing  methods,  except  special  mdications  for 
tt^eir  use. 

I  wish  to  express  my  thanks  to  Miss  Frances  E.  Smith, 
Superintendent,  and  to  the  Nursing  Staff  of  St.  Luke's  Hospital, 
Duluth,  Minn.,  for  cooperation  in  the  development  of  these 
notes. 

To  the  publishers,  J.  B.  Lippincott  Company,  I  also  wish^  to 
extend  my  thanlcs  for  their  earnest  cooperation  in  developing 
my  drawings  and  ideas  for  the  illustrations. 

Archibald  L.  McDonald,  A.B.,  M.D. 

Duluth,  Minnesota. 


CONTENTS 

CHAPTER  PAGE 

I.  Bacteria 1 

II.  Common  Types  of  Local  Infection,  Portals  of  Entry.  ..     19 

III.  Effects  of  Specific  Pathogenic  Bacteria 30 

IV.  Tumors  or  New-Growths 40 

V.  Wounds,  Hemorrhage,  Surgical  Operations   and   Anes- 
thesia   • 49 

VI.  Bones  and  Articulations - 71 

VII.  Vascular,  Lymphatic  and  Nervous  Systems 92 

VIII.  The  Head,  Cranium  and  Face 116 

IX.  The  Neck,  Cervical  Region 140 

X.  Thoracic  Cavity  and  Breast 150 

XI.  The  Abdominal  Cavity,  Walls  and  Peritoneum 159 

XII.  The  Gastro-intestinal  Organs,  Stomach,  Small  and  Large 

Intestine,  Rectum,  Anus,  and  Vermiform  Appendix 172 

XIII.  The  Liver,  Bile-Passages,  Pancreas,  and  Spleen 198 

XIV.  The    Urinary    Organs,    Kidney,    Ureter,    Bladder,    and 

Urethra 207 

Glossary • 223 


ESSENTIALS  OF  SURGERY 

FOR  NURSES 


CHAPTER  I 

BACTERIA 

Knowledge  of  the  fundamental  principles  of  bacteriology 
is  necessary  as  an  introduction  to  surgery  for  the  foUov/ing 
reasons : 

1.  Bacteria  cause  an  important  group  of  surgical  lesions. 

2.  Bacteria  also  cause  serious  complications  following 
surgical  operations. 

3.  Aseptic  technic,  as  used  in  the  operating  or  dressing 
room,  aims  to  prevent  absolutely  the  contamination,  by  bac- 
teria, of  the  wound,  or  anything  which  comes  into  direct  or 
indirect  contact  with  the  operative  field. 

We  must  therefore  call  attention  to  some  of  the  more 
significant  relations  of  bacteria  and  micro-organisms  to  surgery. 

CLASSIFICATIONS 

Countless  groups  of  bacteria  are  distinguished  on  the  basis 
of  shape,  motility,  reaction  to  special  staining  methods,  and  the 
character  of  growth  on  certain  laboratory  "media"  (culture 
material).  Diagnosis  of  the  specific  bacteria  causing  a  given 
lesion  may  be  determined  by  laboratory  studies  of  the  pus, 
secretions,  or  circulating  blood,  by  one  of  the  following  methods : 

(a)  Smears  of  the  material  are  made  on  glass,  slides  and, 
after  being  killed  or  fixed  on  the  slide  by  heat,  are  stained  and 
studied  under  the  microscope. 

(h)  Cultures  are  made  by  implanting  a  minute  amount  of 
the  septic  material  or  circulating  blood  on  special  laboratory 
media.  The  characteristic  method  of  growth  may  thus  be 
determined  and  the  prevailing  organisms  are  classified. 

1 


2  ESSENTIALS  OF  SUHGERY  FOR  NURSES 

Pathogenic  micro-organisms,  i.e.,  those  which  are  able 
to  invade  the  human  body  and  give  rise  to  pathologic  changes, 
are  the  only  ones  of  special  interest  in  this  connection. 

The  NON-PATHOGENIC  BACTERIA,  of  which  there  are  a  great 
variety,  are  of  only  secondary  importance,  since  they  do  not 
cause  disease  in  the  body. 

Aerobic  and  anaerobic  organisms:  This  classification 
is  made  on  the  basis  of  the  relation  of  certain  bacteria  to  oxygen. 

(1)  Aerobic  bacteria,  comprising  the  majority  of  the  patho- 
genic group,  require  oxygen  to  maintain  life.  When  deprived 
of  this  gas,  or  air,  such  bacteria  are  destroyed  or  die. 

(2)  Anaerobic  bacteria,  on  the  contrary,  thrive  best  in  the 
absence  of  free  oxygen,  and  are  killed  in  its  presence.  This 
characteristic  determines  the  habitat  and  distribution  of  certain 
organisms  and  accounts  for  the  fact  that  they  usually  cause 
infection  in  "punctured  wounds,"  i.e.,  where  they  are  remote 
from  the  air  and  free  oxygen.  It  also  indicates  the  methods  of 
treatment  of  such  infected  wounds :  free  incision  and  exposure 
of  the  area.  The  tetanus  and  "gas"  bacilli  (see  page  35)  are 
important  members  of  this  group. 

VARIATIONS  IN  INDIVIDUAL  SPECIES  OF  BACTERIA 

Resistance  to  unfavorable  environment,  including  lack  of 
oxygen,  lack  of  moisture,  heat,  certain  chemical  agents  (germi- 
cides), aU  of  which  tend  to  prevent  the  growth  of  micro- 
organisms or  to  destroy  them,  varies  greatly. 

Spores  are  a  form  assumed  by  certain  types  of  bacteria 
when  they  are  exposed  to  unfavorable  conditions,  and  are 
thereby  rendered  more  resistant  to  destructive  agents.  They 
are  inactive  in  this  state,  survive  ordinary  germicidal  agents, 
but  later  multiply  and  become  active  when  brought  into  a 
normal  environment.  The  varieties  of  bacteria  which  take 
on  spore  form  demand  special  methods  of  sterilization  or  fumi- 
gation; for  example,  repeated  or  prolonged  exposure  to 
unusually  high  temperature,  steam  under  pressure,  or  strong 
germicidal  agents. 

Virulence. — This  refers  to  the  activity  with  which  a  given 
t3^e  of  pathogenic  organism  attacks  the  individual  who  is 
invaded.  A  particular  specific  bacteria  which,  under  certain 
circumstances,  is  relatively  inactive,  i.e.,  of  low  virulence,  will, 


BACTERIA  3 

under  other  conditions,  become  highly  virulent  and  cause  most 
serious  infection.  Example:  A  mild  tonsillitis  in  one  individual 
will  give  a  pure  culture  of  streptococcus,  while  another  person 
suffering  from  a  much  more  severe  form,  with  marked  toxaemia, 
may  show  the  same  type  of  organisms  on  culture.  This  varia- 
tion is  controlled  by  many  factors  which  are  not  clearly  under- 
stood, but  it  determines  to  a  great  extent  the  effects  of  the 
invasion  of  the  body  by  any  given  type  of  bacteria. 

DISTRIBUTION 

Pathogenic  bacteria  of  one  type  or  another  are  found  almost 
universally  in  nature  and  are  assumed  to  be  present  on  any 
object  or  surface  which  has  not  been  rendered  sterile  by  proper 
methods,  and  continuously  protected  from  further  contamina- 
tion. While  bacteria  of  some  type  are  found  in  all  surroundings, 
certain  varieties  are  more  prevalent  in  special  localities  and 
materials.    For  example: 

1.  In  manure,  street-dirt,  about  barns  and  in  fertilized  soil 
are  found  some  of  the  following :  B.  tetanus,  B.  coli,  B.  aerogenes 
capsulatus,  gas  bacillus. 

2.  Sewage  or  material  contaminated  with  human  excreta  is 
likely  to  contain  B.  coli,  typhoid  bacilli,  and  various  groups  of 
streptococci. 

3.  Sputum  and  secretions  from  the  nose  and  mouth  may 
contain  tubercle  bacilli,  diphtheria  bacilU,  pneumococci,  men- 
ingococci or  streptococci. 

4.  Urethral  or  vaginal  discharges  are  always  to  be  regarded 
as  possibly  containing  active  gonococci. 

5.  Hospital  operating  or  dressing  rooms  where  infected 
wounds  are  treated  are  likely  to  show  B.  coli  and  various  types 
of  streptococci  or  staphylococci. 

STERILIZATION 

Sterilization  means  the  destruction  of  all  bacterial  life  on 
any  object  or  in  any  material,  which  is  then  spoken  of  as  being 
sterile  or  aseptic.  Various  methods  of  sterilization  are  adapted 
to  special  materials  or  surfaces  of  the  body.  It  is  not  possible 
to  discuss  the  different  technics  in  detail,  as  each  operating 
room  has  developed  its  special  routine.  Only  experience  in 
the  actual  work  under  an  exacting  superintendent  can  familiar- 


4  ESSENTIALS  OF  SURGERY  FOR  NURSES 

ize  the  student  with  principles  and  methods.  (See  also  such 
books  as  ''The  Operating  Room,"  by  Fowler,  and  ''Aseptic 
Technique,"  by  Robb.) 

An  ANTISEPTIC  or  GERMICIDE  is  an  agent  which  destroys 
bacteria,  including  the  following:  A,  direct  heat;  B,  steam; 
C,  chemicals. 

A.  Heat. — 1.  The  flame  destroys  most  materials,  injures 
many  instruments,  and  is  only  used  in  emergency  for  solid  metal 
instruments  or  glass  slides. 

2.  Baking  is  destructive  to  most  materials  and  is  not  a 
reliable  method. 

B.  Boiling  and  Live  Steam  under  Pressure. — 1.  Boiling  for 
from  10  to  20  minutes  is  used  for  water,  solutions,  metal  instru- 
ments (except  knives,  which  lose  their  temper  and  are  usually 
sterilized  in  carbolic  acid  and  alcohol),  glassware  and  similar 
materials. 

2.  Live  steam  under  pressure  in  an  autoclave  is  necessary 
to  insure  penetration  of  gauze  dressings,  and  to  give  complete 
sterilization.  The  process  is  repeated  on  two  or  more  successive 
days  to  destroy  spores  which  may  be  present. 

C.  Chemicals  in  solutions  of  varying  strength  are  used  under 
conditions  where  neither  of  the  above  methods  is  feasible. 
Some  of  these  are:  Mercury  preparations,  bichloride,  biniodide, 
carbolic  acid  or  its  derivatives — lysolor  liquor  cresoUs  comp., 
tincture  iodine,  boracic  acid,  and  others  less  commonly  used. 

Aseptic  technic  refers  to  a  method  of  procedure  in  the  oper- 
ating or  dressing  room  whereby  everything  that  comes  directly 
or  indirectly  into  contact  with  the  wound  and  tissues  is  sterile 
or  aseptic.  To  be  successful,  there  must  be  no  possible  contami- 
nation of  the  operative  field  or  of  anything  which  comes  in 
contact  with  it,  by  an  object  which  has  not  been  rendered  and 
kept  sterile.  Such  methods  are  used  at  all  operations  and  for 
dressing  any  wound.  It  is  impossible  and  useless  to  describe 
these  in  detail  and  they  can  only  be  acquired  by  prolonged 
experience  in  a  well-regulated  operating  room.  Work  in  a 
bacteriological  laboratory  will  emphasize  the  necessity  for  an 
absolutely  unbroken  technic  to  prevent  contamination  in  any 
aseptic  procedure.    (See  experiments  at  the  end  of  the  chapter.) 

Antiseptic  technic  involves  the  use  of  germicidal  chemical 
solutions  to  prevent  the  growth  of  any  pathogenic  organisms 


BACTERIA 


which  may  be  present.  It  is  used  in  the  case  of  wounds  which 
are  akeady  infected,  or  under  conditions  where  dependable 
asepsis  is  not  possible. 

THE  BODY  IN  RELATION  TO  BACTERIA 

A.  All  of  the  exposed  surfaces  of  the  body,  together  with  the 
membranes  which  line  the  various  cavities  opening  upon  the 
surface,  are  subject  to  contamination  with  bacteria. 

B.  The  surfaces  are  protected  against  invasion  of  pathogenic 
bacteria  by  the  following  factors: 

1.  The  structure  of  each  surface  is  adapted  in  some  degree 
to  the  extent  of  its  exposure  to  bacterial  contamination.    The 


Fig.  1. 


Fig.  2. 


Fig.  1. — Simple  squamous  epithelium. 
Fig.  2. — Stratified  ciliated  columnar  epithelium. 

surface,  being  covered  by  a  complete  intact  layer  of  epithelium 
resting  on  a  basement  membrane,  is  impervious  to  bacteria 
which  are  normally  present.    In  particular  regions : 

The  skin,  mouth,  and  orifices  of  the  various  cavities 
which  are  most  exposed,  are  covered  by  "squamous  stratified 
epithelium,"  which  is  especially  protective  as  compared  to  the 
single-layered  "columnar  epithelium"  of  more  remote  regions 
(Figs.  1  and  2). 

2.  (a)  The  mechanical  effects  of  the  secretions  and  excretions 
of  various  ducts  and  cavities  tend  to  carry  invading  bacteria 
to  the  surface  of  the  body. 


6  ESSENTIALS  OF  SURGERY  FOR  NURSES 

(6)  The  mechanical  effect  of  special  "ciliated  epithelium" 
(example,  the  trachea  and  bronchi)  tends  to  carry  all  foreign 
matter  to  the  throat. 

(c)  The  chemical  and  bactericidal  action  of  certain  secretions 
(hydrochloric  acid  of  the  gastric  juice  and  the  normal  vaginal 
secretion)  is  sufHcient  to  destroy  ordinary  bacterial  invaders. 

{d)  The  activity  of  certain  non-pathogenic  organisms  in  the 
intestinal  tract  tends  to  prevent  the  accumulation  and  growth 
of  pathogenic  bacteria  which  may  be  present. 

C.  All  such  exposed  surfaces  must  be  regarded  as  septic 
and  infected.  Effective  sterilization  is  impossible  without 
destroying  tissues  or  lowering  their  resistance  to  bacterial 
invasion.  While  the  actual  surface  can  be  rendered  free  of 
micro-organisms  by  mechanical  cleansing  and  the  use  of  germi- 
cidal solutions,  bacteria  penetrate  to  the  deeper  epithelial 
layers,  or  into  the  sweat,  sebaceous  or  mucous  glands,  and 
escape.    This  fact  is  important  from  two  standpoints: 

1.  The  preparation  of  the  surgeon's  hands  for  aseptic  opera- 
tions. It  is  assumed  that  careful  cleansing  and  the  use  of  a 
chemical  germicide  according  to  some  accepted  method  is 
sufficient  to  remove  and  destroy  all  pathogenic  germs  on  the 
skin,  and  that  those  in  the  deeper  layers  are  not  likely  to  reach 
the  surface  and  contaminate  the  wound,  sterile  instruments 
and  dressings.  However,  the  surgeon  rarely  depends  entirely 
upon  such  methods,  but  wears  sterile  rubber  gloves  for  all 
operations  and  often  for  dressings.  This  is  for  one  of  two 
purposes:  (a)  To  prevent  the  contamination  of  aseptic  wounds 
or  tissues  in  non-infected  cases;  (6)  to  protect  his  own  hands 
in  treating  septic  or  infected  wounds  and  to  avoid  any  secondary 
invasion  by  other  pathogenic  organisms.  In  dressing  wounds 
without  gloves,  sterile  instruments  are  used  extensively,  and 
all  contact  with  the  hands  is  avoided. 

2.  Contaminated  surfaces  as  a  source  of  infection  of  pene- 
trating wounds.  The  skin:  Ordinary  surgical  preparation 
removes  or  destroys  practically  all  pathogenic  bacteria  which 
may  be  present.  The  local  blood-supply  is  rich  enough  to 
overcome  most  of  the  accidental  invading  organisms.  At  times 
bacteria  from  the  deep  layers  which  have  escaped  sterilization 
invade  a  wound  through  the  surface  and  cause  local  infection. 
The  so-called  ''stitch  abscess"  is  formed  by  such  organisms, 


BACTERIA  7 

causing  infection  which  extends  along  sutures  penetrating  the 
skin.  Other  epithehal  surfaces — mouth,  intestinal  tract,  and 
vagina — are  constantly  exposed  to  bacterial  contamination  and 
are  considered  as  infected  or  septic.  Local  sterilization  of 
these  regions  is  even  less  successful  than  is  the  case  with  the 
skin,  and  wounds  soiled  with  the  contents  of  such  cavities 
must  always  be  regarded  as  infected. 

D.  Bacteria  which  are  'present  on  such  epithelial  surfaces 
or  in  the  various  epithelial  lined  cavities  are  practically  outside 
of  the  body,  and  are  harmless  till  they  have  broken  through 
the  epithelium  and  have  actually  invaded  tissue  cells.  In  order 
for  harm  to  occur,  we  presuppose  a  definite  "portal  of  entry," 
i.e.,  a  destruction  of  the  intact  protective  epithelium,  or  an 
opening  (wound)  through  which  pathogenic  bacteria  and  toxins 
reach  the  tissue  cells  and  body  fluids,  where  they  may  be  taken 
up  by  the  circulation. 

A  portal  of  entry  may  occur  as  the  result  of  one  of  the 
following  conditions: 

1.  Wounds,  intentional  operative  wounds  or  those  which 
are  the  result  of  accidental  injury. 

2.  Injury  or  irritation  resulting  in  lowered  local  resistance, 
destruction  of  epithelium,  ulcer  formation,  or  an  area  of  gangrene. 

3.  The  accumulation  of  an  unusual  number  of  actively 
virulent  organisms  may  be  sufficient  to  destroy  the  protective 
epithelium  and  establish  a  portal  of  entry,  especially  when 
associated  with  local  irritation  or  lowered  resistance. 

4.  It  is  claimed  that  bacteria  may  penetrate  an  intact 
epithelial  surface  (intestinal)  and  cause  infection  in  the  under- 
lying tissues,  with  no  demonstrable  portal  of  entry.  (Examples 
of ''  portals  of  entry  "  to  an  infected  wound :  tonsillitis,  an  abscess 
in  any  location,  typhoid  ulcers  in  the  intestine.) 

EFFECTS  OF  BACTERIA  ON  THE  BODY 

The  factors  which  determine  the  results  of  a  given  infectious 
process  are: 

A.  On  the  part  of  the  invading  organism: 

1.  The  SPECIFIC  NATURE  of  the  bacteria  in  question.  Each 
type  of  pathogenic  organism  causes  more  or  less  typical  results 
and  has  a  special  tendency  to  attack  certain  regions  or  tissues. 
These  peculiarities  will  be  discussed  in  detail  in  a  later  section. 


8  ESSENTIALS  OF  SURGERY  FOR  NURSES 

2.  The  NUMBER  of  organisms  reaching  the  tissues  will,  to 
a  certain  extent,  determine  the  severity  of  the  process. 

3.  The  VIRULENCE  of  a  given  organism  varies,  and  is  a  most 
important  factor  influencing  the  local  and  general  effects  of 
bacterial  invasion. 

B.  On  the  part  of  the  individual  thus  infected : 

1.  Specific  protection,  that  is,  certain  persons  have 
acquired  an  especially  increased  resistance  or  relative  immunity 
to  a  given  type  of  pathogenic  micro-organisms.  In  the  case 
of  a  few  of  the  non-surgical  infections,  this  immunity  may  be 
hereditary.  More  often  it  is  acquired  by  previous  exposure 
to  a  relatively  inactive  process  caused  by  the  organism  in 
question,  or  by  a  mild  attack  of  the  disease  (smallpox).  In 
some  cases  it  may  be  developed  therapeutically  by  the  use  of 
"vaccines,"  i.e.,  the  individual  is  inoculated  with  killed  organ- 
isms of  a  given  type  of  bacteria. 

2.  General  Resistance. — Anything  which  impairs  the 
health  of  the  individual  lessens  the  ability  of  the  body  to  over- 
come the  activity  of  the  invading  micro-organisms.  Such  con- 
ditions include,  (a)  chronic  infections,  tuberculosis  and  syphilis; 
(6)  constitutional  disease,  diabetes,  arteriosclerosis,  nephritis,' 
and  certain  diseases  of  the  central  nervous  system;  (c)  alcohol- 
ism, chronic  intoxication,  fatigue,  exhaustion,  or  malnutrition. 

3.  Local  resistance  determines  to  a  great  extent  the  course 
of  the  original  portal  of  entry,  or  primary  lesion. 

(a)  The  chief  factor  is  the  richness  of  the  normal  blood 
supply  to  the  area  involved.  In  regions  where  this  is  abundant, 
a  greater  number  of  the  invading  bacteria  are  quickly  overcome, 
and  the  process  runs  a  shorter  course.  Also,  because  of  the 
rich  vascular  supply,  there  is  greater  absorption  of  toxins  and 
more  marked  constitutional  effects.  In  regions  which  have  a 
scanty  blood  supply,  as  in  fatty  tissue  (perirectal  space), 
invading  bacteria  meet  less  resistance,  there  is  greater  tissue 
destruction,  and  at  the  same  time  less  absorption  of  toxins 
and  constitutional  results. 

(b)  As  a  result  of  pathological  change  in  the  vascular 
system,  the  normal  blood  supply  is  interfered  with,  and  there 
is  decreased  resistance  to  bacterial  invasion.  Example,  partial 
obstruction  of  the  principal  artery  to  a  part,  resulting  in  lessened 
blood  supply;  or  partial  obstruction  of  the  veins  from  a  region, 


BACTERIA 


resulting  in  stasis  of  blood  in  the  tissues  and  a  passive  congestion, 
as  seen  in  varicose  veins  of  the  limb  affected  wath '4eg  ulcers/' 

(c)  The  normal  nerve  supply  to  a  region  is  important  in 
maintaining  the  'Hone"  of  the  tissues,  and  their  ability  of 
resisting  invading  organisms.  Constitutional  or  local  dis- 
turbances, which  impair  the  normal  nerve  supply,  seriously 
lower  the  local  resistance  to  an  infectious  process. 

Infection  or  sepsis,  the  effects  of  invasion  of  the  body 
by  pathogenic  bacteria:  These  terms  refer  respectively  to: 
(A)  the  local  and  (B)  the  constitutional  changes  which  are  caused 
by  pathogenic  bacteria. 


Fig.  3. — Showing  tissue  changes  in  inflammation. 

A.  The  local  effects,  inflammation,  represent  the  attempt 
of  the  tissues  of  the  body  to  overcome  and  destroy  invading 
pathogenic  organismus.  These  changes  vary  somewhat  in  special 
tissues,  and  with  different  types  of  bacteria,  but  are  fairly 
constant.  The  details  have  been  studied  experimentally  and 
clinically,  and  a  general  knowledge  of  these  is  important  in 
order  to  understand  the  process  (Fig.  3). 

There  is  found  in  the  area  thus  involved : 

1.  An  increased  local  blood  supply.  There  is  an  active 
dilatation  of  the  arterioles,  capillaries,  and  veins,  so  that  more 
blood  passes  through  the  tissues  in  a  given  time. 


10        ESSENTIALS  OF  SURGERY  FOR  NURSES 

2.  Blood-serum  and  white  blood  cells  (leucocytes)  pass 
through  the  walls  of  the  capillaries  into  the  tissue  spaces.  Here 
the  leucocytes  attack  and  destroy  invading  bacteria,  and  because 
of  this  activity,  the  term  "phagocyte"  is  applied  to  them. 

3.  Development  of  plasma  cells  is  observed  microscopi- 
cally in  the  tissues.  These  cells  have  a  characteristic  appearance 
and  their  functions  include  the  formation  of  a  more  or  less 
complete  layer  about  the  invaded  area,  which  tends  to  limit 
the  process, 

4.  Swelling,  due  to  the  increased  blood  supply  and  the 
presence  of  an  abnormal  amount  of  fluid  and  cells  in  the  tissues. 

5.  Pain,  as  a  result  of  distention  of  the  tissues  and  pressure 
on  the  sensitive  nerve-endings.  This  depends  on  the  density 
of  the  tissues,  being  greater  in  firm  resisting  structures  (sub- 
periosteal) and  less  in  loose  fatty  tissues  (subperitoneal) ;  where 
a  considerable  amount  of  tissue  destruction  may  develop  with 
but  little  pain. 

6.  Increased  local  temperature  and  redness  (if  super- 
ficial), due  to  the  vasodilatation  and  increased  local  blood  supply. 

The  course  of  the  local  inflammatory  process  depends 
on  the  factors  *'A"  and  "B"  discussed  under  this  section, 
"Effects  of  Bacteria." 

1.  Resolution,  most  favorable.  The  invading  organisms  are 
overcome  and  killed  by  the  phagocytic  activity  of  the  white 
blood-cells.  These,  together  with  any  necrotic  (killed)  body 
and  blood-cells,  are  entirely  absorbed,  and  the  process  is  termi- 
nated spontaneously. 

2.  Suppuration,  less  favorable.  In  this  case  large  numbers 
of  tissue  and  blood-cells  are  destroyed,  forming  pus.  Pus  is 
fluid,  consisting  of  dead  (necrotic)  blood-cells,  tissue  cells, 
blood-serum,  and  usually  contains  bacteria,  some  killed  and 
some  actively  virulent.  The  local  process  in  diffuse  tissues  is 
spoken  of  as  "cellulitis,"  and  later  forms  a  definite  "abscess." 
As  a  result  of  the  presence  of  fluid  pus,  the  surgeon  can  usually 
demonstrate  a  characteristic  sign,  fluctuation,  if  the  process  is 
superficial.  When  inflammation  has  gone  on  to  suppuration, 
complete  resolution  rarely  occurs,  and  one  of  the  two  following 
possibilities  may  result: 

3.  Encapsulation  (a  favorable  process).  This  consists  of 
a  complete  walling  off  of  the  area  of  inflammation  by  a  layer, 


BACTERIA  11 

composed  of  plasma  and  connective-tissue  cells,  which  is  im- 
pervious to  the  active  bacteria  or  the  products  of  their  activity. 
By  this  means  the  abscess  or  cellulitis  is  effectively  sealed  up 
and  localized.  Such  a  cavity  contains  pus  and  bacteria,  which 
under  favorable  circumstances  are  destroyed,  so  that  eventually 
the  contents  are  practically  sterile,  and,  theoretically,  the  mass 
may  be  absorbed.  An  encapsulated  abscess  is  a  source  of  danger 
in  that  it  may  contain  pathogenic  bacteria  of  low  virulence, 
which  again  become  active  and  give  rise  to  an  extension  of  the 
process  if  the  general  resistance  is  later  below  normal. 

The  first  two  stages  can  be  observed  "in  miniature"  by  the 
course  of  small  papules  or  pustules  in  the  skin.  The  milder 
ones  appear  as  red,  painful  swellings,  representing  the  reaction 
of  the  tissues  to  pathogenic  bacteria  which  are  killed  without 
extensive  destruction  of  body-cells.  Pustules  result  when  a 
certain  number  of  tissue  and  blood-cells  are  destroyed,  forming 
fluid  pus,  visible  as  a  white  area  at  the  centre.  If  the  process 
is  deeper  it  may  become  sealed  off  and  '^ encapsulated"  as  a 
tender  palpable  nodule.  ''Sinus  formation"  is  represented  by 
sloughing  of  necrotic  overlying  epithelium  and  spontaneous 
dischajrge  of  pus. 

4.  Unfavorable  course,  extension  of  the  area  of  suppuration, 
diffuse  cellulitis.  This  process  extends  and  is  limited  only  by 
dense  fibrous  membranes,  such  as  "aponeuroses,"  sheathes  of 
muscles,  or  peritoneum. 

5.  Sinus  Formation. — The  most  favorable  natural  result  at 
this  stage  is  a  spontaneous  rupture  of  the  abscess  to  the  surface 
or  into  one  of  the  hollow  organs,  since  this  provides  an  outlet 
for  the  septic  and  necrotic  material.  Such  spontaneous  opening 
is  the  natural  provision  for  drainage  of  an  abscess,  and  it  will 
persist  as  long  as  there  is  necrotic  material  in  the  cavity.  If 
drainage  is  complete,  the  protective  tissue  develops  and  fills  in 
the  abscess  cavity,  completing  the  healing  process.  In  many 
cases  the  sinus  persists,  and  it  is  necessary  to  enlarge  the  open- 
ing and  remove  necrotic  tissue  to  secure  closure  of  the  cavity. 
Usually  the  surgeon  is  able  to  anticipate  spontaneous  sinus 
formation  by  incision,  and  to  provide  more  adequate  drainage. 
This  is  preferable  for  the  following  reasons:  (a)  Surgical  in- 
cision provides  more  efficient  drainage,  often  at  a  more  favorable 
site;  (6)  it  is  done  earlier  and  avoids  extensive  destruction  of 


12        ESSENTIALS  OF  SURGERY  FOR  NURSES 


healthy  tissue;  (c)  it  allows  complete  evacuation  of  the  cavity; 
(d)  it  leaves  healthier  tissue  and  healing  is  more  rapid  and 
complete. 

B.  General  or  constitutional  results  are  those  which  are 
more  or  less  remote  from  the  primary  focus  of  bacterial  invasion. 
These  include: 

1.  Involvement  of  the  lymph-vessels  and  lymph- 
nodes.  The  student  should  review  the  physiology  of  the  lym- 
phatic circulation  (Fig.  4).  Lymph 
vessels  drain  fluid  from  the  tissues. 
This  fluid  (lymph)  is  derived  prima- 
rily from  the  blood-serum  which  has 
passed  into  the  intracellular  spaces 
in  the  tissues,  and  is  in  turn  taken 
up  by  the  lymph  vessels,  finally 
being  emptied  into  the  venous 
circulation  through  the  right  and 
left  thoracic  ducts. 

The  lym-ph-nodes  are  definite 
masses  composed  of  cells  repre- 
senting different  stages  of  develop- 
ing lymphocytes,  and  are  located 
in  various  parts  of  the  body.  The 
lymph-nodes  have  two  functions, 
(a)  they  supply  Ijrmphocytes  to  the 
circulating  blood;  (6)  the  lymph 
from  the  tissues  passes  through  one 
or  more  sets  of  lymph-nodes  which 
tend  to  overcome  and  destroy  any 
harmful  material,  bacteria  or  toxins, 
which  reaches  them,  and  in  this  man- 
ner protect  the  general  circulation. 
This  second  function  is  particularly 
important  in  connection  with  infectious  processes  in  the  body. 
When  superficial  lymph  vessels  are  involved,  this  is  made 
evident  by  red  streaks  under  the  skin,  representing  the  lymph 
vessels  irritated  by  the  inflammatory  extension.  The  affected 
lymph-nodes  "hypertrophy,"  or  enlarge,  as  a  result  of  the 
attempt  to  overcome  the  invading  micro-organisms  and  toxins. 
(See  experiments  and  demonstrations.) 


Fig.  4. — Lymphatic  circulation. 


BACTERIA  13 

The  involvement  of  the  neighboring  lymph-nodes  will  persist 
until  the  original  process  has  cleared  up,  or  adequate  drainage 
has  been  provided.  Under  favorable  conditions,  extension  to 
more  remote  parts  of  the  body  is  prevented  and  the  process  in 
the  lymph-nodes  subsides  without  serious  tissue  destruction, 
being  controlled  by  prompt  and  successful  treatment  of  the 
original  lesion.  In  less  favorable  cases,  extensive  tissue  necrosis 
and  suppuration  occurs  in  the  involved  lymph-nodes.  It  is 
then  necessary  to  consider  this  process  on  the  principles  of 
independent  abscess  formation  or  cellulitis,  spontaneous  reso- 
lution rarely  taking  place. 

2.  Involvement  of  the  blood,  leucocytosis,  represents  a 
further  protective  process,  and  consists  of  an  increase  in  the 
total  number  of  white  blood-cells  in  response  to  the  activity 
of  the  micro-organisms.  This  reaction  is  found  in  practically 
all  infectious  processes,  except  typhoid  and  tuberculosis.  A 
leucocytosis  is  demonstrated  by  a  "blood  count,"  i.e.,  counting 
the  white  blood-cells  in  a  given  volume  of  a  known  dilution  of 
blood,  using  special  pipettes  and  ruled  slides,  under  the  micro- 
scope. Normally  in  a  cubic  mm.  of  blood  there  are  found  from 
5000  to  7000  leucoc3^fces,  and  any  considerable  increase,  i.e., 
over  8000,  is  evidence  of  a  leucocytosis.  The  degree  of  this 
reaction  is  determined  by  the  virulence  of  the  infectious  process 
and  the  resistance  of  the  individual.  Differential  counts  are 
made  by  estimating  the  percentage  of  each  type  of  white  blood- 
cell  in  a  stained  blood-smear.  The  relative  increase  of  various 
forms  of  leucocytes  varies  and  is  of  importance  in  estimating 
the  resistance  to  the  particular  infection  present. 

3.  Toxemia,  or  sepsis.  The  constitutional  reaction  due  to 
absorption  of  toxins  and  products  of  tissue  destruction  is  com- 
monly spoken  of  as  "sepsis,"  and  is  present  to  a  greater  or  less 
degree  in  all  infectious  processes.  The  condition  may  be 
(a)  acute,  i.e.,  sudden  onset,  rapid  increase  in  the  severity  of 
symptoms,  which  may  either  go  on  progressively  to  a  fatal 
termination,  or  clear  up  rapidly  following  a  more  or  less  definite 
"crisis"  in  response  to  treatment;  (h)  a  chronic  condition  of 
sepsis  may  follow  an  acute  process,  or  in  other  cases  is  chronic 
from  the  beginning. 

The  evidences  of  acute  sepsis  are:  (a)  Chill  at  the  onset  or 
associated  with  a  suddenly  increased  absorption  of  toxic  prod- 


14        ESSENTIALS  OF  SURGERY  FOR  NURSES 

ucts.  (6)  Fever,  a  sharp  rise  of  temperature  to  103**  or  higher, 
which  may  be  irregular,  (c)  Increased  pulse,  to  120  or  more, 
usually  in  proportion  to  the  fever.  The  pulse-rate  rises  with 
the  severity  of  the  toxaemia,  and  in  serious  cases  becomes  weak 
and  irregular,     (d)  Headache  and  malaise  are  usually  present. 

The  chronic  type  of  sepsis  is  gradual  in  onset  or  may  repre- 
sent the  termination  of  an  acute  process.  Fever  is  rarely  as 
high  as  in  the  acute  type  and  is  quite  irregular,  with  character- 
istic morning  and  evening  variations.  The  pulse-rate  is  also 
increased  and  variable.  The  process  is  slow  in  progress  and 
clears  up  gradually,  or  the  patient  becomes  progressively 
weaker,  and  dies.  In  the  long-standing  cases  there  is  marked 
malaise,  cachexia,  malnutrition,  with  kidney  changes,  albumi- 
nuria, or  anuria. 

Significance  of  Constitutional  Symptoms. — These  always 
indicate  the  presence  of  an  active  focus  of  infection  from  which 
toxic  material  is  being  absorbed,  (a)  When  such  symptoms 
arise  spontaneously  in  a  patient  previously  well,  it  is  necessary 
to  locate  the  primary  lesion  and  treat  the  condition  as  may  be 
indicated.  (6)  The  persistence  or  recurrence  of  evidences  of 
sepsis  after  a  local  lesion  has  been  treated  surgically  indicates 
that  drainage  is  insufficient,  or  that  some  lesion  has  been  over- 
looked, (c)  The  development  of  fever  and  other  symptoms 
following  a  clean  surgical  operation  should  be  taken  as  evidence 
of  infection  in  the  wound. 

4.  Septicemia  (literally  septic  blood)  is  characterized  by 
the  presence  of  pathogenic  bacteria  in  the  circulating  blood. 
Bacteria  from  a  focus  of  infection  reach  the  neighboring  veins, 
are  taken  up  by  the  general  circulation,  and  are  carried  to  all 
parts  of  the  body.  Demonstration  of  the  organisms  in  the 
circulation  is  made  by  means  of  bacteriologic  cultures  of  blood 
drawn,  under  aseptic  precautions,  from  a  superficial  vein. 

Significance:  Such  a  condition  is  evidence  of  a  virulent 
infection  which  has  overcome  the  defensive  processes,  and 
indicates  a  grave  prognosis. 

5.  Pyemia  refers  to  a  condition  when  there  are  multiple 
areas  of  infection  in  various  parts  of  the  body.  The  veins  in 
the  tissues  about  the  primary  infectious  focus  contain"  thrombi," 
i.e.,  clots,  in  which  are  found  virulent  pathogenic  bacteria.  Parts 
of  these  thrombi  loosen,  are  carried  in  the  blood  a§  "efflboli," 


BACTERIA  15 

and  later  lodge  in  remote  parts  of  the  body,  giving  rise  to  many- 
secondary  areas  of  infection.  Pysemia  develops  when  general 
resistance  to  the  specific  causal  organisms  is  exceedingly  low. 
The  condition  indicates  a  bad  prognosis. 

Principles  of  Treatment. — There  are  three  indications: 

A.  To  cut  off  the  absorption  of  toxins  from  the  local  focus 
of  infection. 

B.  To  promote  the  elimination  of  toxic  material  already 
absorbed. 

C.  To  increase  the  general  body  resistance,  and,  in  certain  cases, 
also  the  specific  resistance  to  the  causal  pathogenic  organisms. 

(A)  Local  Treatment. — As  soon  as  it  can  be  demonstrated 
that  there  is  a  definite  local  lesion  accessible  to  surgical  treat- 
ment, attempts  are  made  to  control  the  infectious  process  at 
this  point.  (1)  The  ideal  method  is  an  "excision,"  removal 
of  the  entire  focus,  which  is  possible  only  when  the  infection  is 
limited  entirely  to  a  structure  which  can  be  removed  surgically; 
example,  an  acutely  inflamed  appendix  in  the  early  stage.  In 
case  this  is  successful,  there  should  be  a  prompt  cessation  of 
constitutional  symptoms,  and  any  recurrence  is  evidence  of  a 
continuation  or  extension  of  the  original  focus.  (2)  In  cases 
where  excision  is  not  possible,  the  surgeon  attempts  to  control 
the  process  by  (a)  incision  of  the  abscess,  (6)  evacuation  of 
necrotic  and  septic  material,  and  (c)  provision  for  adequate 
drainage.  When  this  is  accomplished,  evidences  of  sepsis  should 
disappear,  provided  drainage  is  good  and  there  is  no  extension 
of  the  abscess,  (d)  Drainage  is  stimulated  by  measures  which 
increase  the  local  blood  supply:  hot,  moist  dressings,  hyper- 
semia  by  special  apparatus,  and  tubes  to  keep  the  incision  open 
till  the  cavity  heals  from  the  bottom.  Otherwise  septic  material 
is  retained  and  may  be  encapsulated,  (e)  Local  resistance  is  also 
increased  by  these  measures  and  by  immobihzation  and  eleva- 
tion of  the  part.  An  ice-bag  is  of  value  to  relieve  pain,  but  does 
not  increase  local  resistance. 

(B)  General  Treatment. — By  this  we  endeavor  to  secure 
(l)  elimination  of  toxins  already  absorbed;  (2)  to  increase  the 
general  resistance,  and  (3)  the  special  resistance  to  the  particular 
infection  involved. 

1.  Elimination  of  toxins  is  accomplished  by  stimulating 
all  of  the  excretions  of  the  body :    (a)  Skin,  by  various  forms  of 


16        ESSENTIALS  OF  SURGERY  FOR  NURSES 

hydrotherapy,  cool  or  cold  baths  or  sponges  as  for  fever;  sponges 
and  alcohol  rubs  to  improve  the  circulation  of  the  skin.  Siveating 
is  induced  by  hot  drinks,  heat  externally,  and  special  drugs, 
"diaphoretics,"  Ex.  Dover's  powder,  aspirin  or  "coal-tar" 
products,  which  also  tend  to  reduce  temperature.  (6)  The 
kidneys :  Large  amounts  of  water  or  fluids  are  given  by  mouth 
to  increase  the  excretion  of  urine,  "diuretic"  drugs,  potassium 
citrate,  cream  of  tartar,  lemonade,  are  used  to  stimulate  the 
activity  of  the  kidneys  and  also  the  elimination  of  toxins  result- 
ing from  sepsis,  (c)  The  bowels:  Constipation  is  a  common 
condition  in  many  of  the  acute  and  chronic  infections.  An 
active  cathartic,  such  as  castor  oil,  magnesium  sulphate,  or  a 
single  dose  of  calomel,  followed  by  a  saline  (magnesium  sulphate 
or  citrate)'  is  usually  indicated  at  the  onset  as  a  part  of  the 
initial  treatment  of  most  acute  infections,  except  where  there 
is  a  possible  involvement  of  the  peritoneum.  After  this  it  is 
necessary  to  keep  the  bowels  well  open  by  the  use  of  milder 
cathartics  or  enemas. 

2.  The  GENERAL  RESISTANCE  of  the  individual  is. maintained 
and  increased  by  medical  and  hygienic  measures,  particularly: 
(a)  Rest  in  bed,  at  an  even  temperature,  thereby  conserving 
the  energy  of  the  body  that  it  may  be  used  in  overcoming  the 
infection.  (6)  Nourishment  which  the  individual  can  digest 
and  which  will  supply  the  greatest  amount  of  energy.  Forced 
feeding  and  special  attention  to  provide  attractive,  nutritious 
foods,  which  will  be  easily  digested,  is  always  necessary,  (c) 
Air  and  sunshine  are  most  important  in  securing  rest,  sleep, 
stimulating  the  appetite,  and  improving  the  general  well-being 
of  the  patient.  If  weather  permits,  treatment  on  a  sun-porch 
or  in  the  open  air  is  often  advised,  (d)  Drugs  are  of  secondary 
importance,  being  indicated  to  meet  special  conditions:  Dia- 
phoretics, diuretics,  or  cathartics,  as  already  mentioned;  tonics 
and  bitters  for  the  appetite;  camphor,  digitahs,  or  strychnine, 
as  indicated  for  special  stimulation;  iron  or  arsenic  for  anaemia, 
morphine  or  hypnotics  to  relieve  pain  or  secure  sleep.  Specific 
medication:  Quinine  for  malaria,  potassium  iodide,  mercury 
or  arsenic  preparations  for  syphilis. 

3.  The  SPECIFIC  resistance  to  certain  special  infections 
may  be  increased:  (a)  By  the  use  of  vaccines;  the  injection  of 
killed  bacteria  of  the  type  causing  the  infection,  which  increases 


BACTERIA  17 

the  body  resistance  to  these  particular  organisms.  These  may 
be  (i)  autogenous  vaccines,  i.e.,  bacteria  which  are  grown  on 
laboratory  media  by  implanting  some  of  the  discharge  or  secre- 
tion from  the  lesion  under  treatment.  These  are  supposed  to 
be  more  definitely  specific  in  a  given  case,  (ii)  Stock  vaccines 
containing  various  combinations  of  organisms  are  on  the  market 
and  are  extensively  used  where  the  specific  causal  organisms 
can  be  demonstrated.  (6)  Antitoxic  serums  are  used  in  infec- 
tions where  the  causal  organisms  produce  soluble  toxins.  Ex- 
ample, tetanus,  diphtheria,  (c)  Tuberculin  in  some  form  is 
used  specifically  in  suitable  cases  of  surgical  tuberculosis. 

PRACTICAL  DEMONSTRATIONS,  WHICH  WILL  DO  MUCH  TO 
MAKE  REAL  THE  PRINCIPLES  AND  FACTS  DESCRIBED  IN 
THE  PRECEDING  PAGES 

1.  To  show  the  effects  of  sterilization  and  the  possibihty  of  bacterial 
contamination. 

1.  Take  two  sterile  petri  dishes  filled  with  culture  media  (agar). 

(a)  Keep  carefully  covered  and  uncontaminated. 

(6)  Uncover  for  a  few  minutes,  expose  to  the  air  and  breathe 
over  the  surface.  Incubate  both  dishes  at  body  tem- 
perature, and  study  in  24,  48,  and  72  hours. 

2.  Take  two  petri  dishes  as  before. 

(a)  Into  one  introduce  a  sterile  surgical  needle  under  absolute 
aseptic  precautions. 

(6)  Into  the  other  dish,  and  under  the  same  precautions, 
introduce  a  needle  which  has  been  steriUzed  but  which 
subsequently  has  been  handled  and  passed  through 
soiled  dressings.  Incubate  as  before  and  study  after 
24,  48,  and  72  hours. 

3.  After  thoroughly  wasliing  the  hands  in  soap  and  water  (no  anti- 

septic) scrape  the  skin  with  a  sterile  knife-blade  and  allow  the 
loosened  epithehum  to  fall  on  the  surface  of  a  sterile  agar 
plate.     Incubate  and  study  as  in  other  experiments. 

4.  After  having  prepared  the  hands  as  for  surgical  cleansing  and 

subsequently  rinsed  thoroughly  in  sterile  water,  to  remove 
any  antiseptic,  loosen  bits  of  epithehmn  about  the  roots  of 
the  nail  and  under  the  nail,  and  drop  on  the  surface  of  an  agar 
plate  with  all  aseptic  precautions.  Incubate  and  study  as 
before. 
II.  To  show  bacterial  contamination  of  body  surfaces. 

1.  (a)  Carefully  swab  the  region  of  the  tonsil  with  a  sterile  appli- 
cator and  wipe  off  on  a  clean  glass  shde.  Allow  to  dry 
and  "fix"  by  passing  through  an  alcohol  flame  5  or  6 
times.  Stain  with  a  few  drops  of  aqueous  solution  of 
methylene  blue,  wash,  diy  and  study  under  the  oil 
immersion. 
(&)  Inoculate  an  agar  tube  of  media  with  a  second  swab, 
incubate  and  study  after  24,  48,  and  72  hours. 
2 


18        ESSENTIALS  OF  SURGERY  FOR  NURSES 

2.  Collect  a  few  drops  of  vaginal  or  urethral  discharge. 

(a)  Make  a  smear  of  a  clean  glass  sUde,  fix  and  stain  with 

methylene  blue,  (i)  Under  the  low  power  microscope, 
study  vaginal  or  urethral  epitheUvun  and  pus  cells, 
(ii)  Under  the  oil  immersion,  study  bacteria  and  pus 
cells. 

(b)  Inoculate  tubes  or  plates  of  suitable  media,  incubate  and 

study. 

III.  Make  the  same  demonstrations  from  an  open  ulcerating  surface. 

IV.  Have  the  nurse  make  a  leucocyte  count  from  a  suitable  case. 

V.  Study  "blood-smears"  under  the  oil   inunersion  and  demonstrate 
various  types  of  leucocytes. 
VI.  From  the  hospital  wards  select  suitable  cases  for  demonstration, 
or  at  least  case-histories  for  special  study,  as  follows: 
(a)  Local  infection,  "felon,"  with  constitutional  symptoms. 
(6)  Local  infection,  superficial  abscess,  with  IjTnphatic  involve- 
ment, if  possible  accompanied  with  suppuration  in  the 
Ijmaph-nodes. 

(c)  A  chronic  discharging  sinus,  osteomyelitis,  before  and  after 

radical  surgical  treatment. 


CHAPTER  n 

COMMON  TYPES  OF  LOCAL  INFECTIONS,  "PORTALS 
OF  ENTRY" 

Certain  forms  of  local  inflammatory  lesions  warrant  special 
mention : 

A.  Cellulitis  represents  the  most  common  local  process.  It 
begins  diffusely  in  the  tissues  associated  with  inflammatory 
reaction,  attempts  at  localization,  encapsulation,  or  abscess 
formation.  The  severity  of  the  reaction  depends  upon  the 
richness  of  the  blood-supply  in  the  area  involved,  being  less 
active  in  loose  fatty  tissues  (perirectal  or  perirenal  regions), 
where  extensive  suppuration  and  large  abscesses  may  develop 
with  but  few  localizing  symptoms.  Such  abscesses  tend  to 
spread  by  gravity  or  by  continuity  in  the  tissues,  being  limited 
only  by  the  more  dense  fibrous  membranes:  periosteum,  apo- 
neuroses or  sheaths  of  muscles.  Example,  tuberculosis  of  the 
lumbar  vertebrse,  "Pott's  disease/'  often  extends  into  the  psoas 
muscle,  which  is  attached  to  these  bones.  Suppuration  takes 
place  in  the  muscle  sheath,  forming  the  "  psoas  abscess, "  which 
"points"  or  tends  to  open  near  the  insertion  of  that  muscle  in 
the  groin. 

"Cold  abscesses"  are  those  which  develop  with  but  slight 
local  reaction,  and  there  is  relatively  little  evidence  of  inflam- 
mation, hence  the  name  cold  abscess.  The  process  is  often 
tubercular. 

B.  Sinuses  are  spontaneous  openings  from  an  abscess  which 
has  extended  to  the  surface  and  has  destroyed  the  superficial 
layers.  A  sinus  provides  an  outlet  for  toxic  and  necrotic  material, 
but  such  drainage  is  usually  less  efficient  than  that  obtained  by 
free  surgical  incision.  A  sinus  persists  usually  as  long  as  necrotic 
material  remains  in  the  cavity.  Premature  closure  results  in 
the  encapsulation  of  the  abscess,  which  may  later  break  through 
and  discharge.  This  is  especially  marked  when  the  sinus  com- 
municates with  a  cavity  containing  necrotic  bone,  as  in  a  long- 
standing case  of  osteomyelitis. 

19 


20        ESSENTIALS  OF  SURGERY  FOR  NURSES 

Secondary  infection  of  the  walls  of  a  sinus  and  abscess 
cavity  frequently  occurs  from  bacteria  present  on  the  surface, 
and  not  the  original  cause  of  the  infection.  Example:  A  tuber- 
culous abscess  with  a  sinus  often  becomes  contaminated  with 
staphylococci,  the  walls  becoming  thickened  and  indurated. 
A  sinus  may  also  follow  a  surgical  incision  into  an  abscess  as  a 
result  of  secondary  infection  or  incomplete  drainage. 

Non-operative  treatment  consists  of  injection  of  the  sinus 
and  cavity,  with  antiseptic  mixtures;  example,  bismuth  paste, 
but  is  ineffective  when  there  are  masses  of  necrotic  material  in 
the  cavity.  A  Rontgen  ray  plate  taken  after  the  injection  of 
the  sinus  with  bismuth  mixture  is  of  value  in  determining  the 
position  of  the  abscess  and  the  course  of  the  sinus. 

Surgical  treatment  aims:  (1)  To  evacuate  necrotic  material 
from  the  cavity,  and  is  accomplished  by  free  incision,  removal 
of  broken-down  tissue,  by  the  curette  if  necessary;  (2)  to  pro- 
vide healthy  walls,  by  curetting  the  surface,  application  of 
strong  antiseptics,  phenol  or  iodine,  or,  most  often,  by  the 
excision  of  the  entire  tract;  (3)  to  secure  complete  closure  from 
the  bottom  of  the  cavity  by  packing  with  iodoform  gauze, 
which  is  gradually  withdrawn. 

C.  A  fistula  is  an  abnormal  opening  between  one  of  the 
hollow  organs  and  the  surface  of  the  body,  or  between  two 
adjacent  hollow  organs.  The  subject  is  discussed  in  this 
Section,  since  it  is  often  due  to,  or  is  usually  comphcated  by, 
local  inflammatory  reactions. 

The  causes  of  fistula  are: 

1.  Congenital,  maldevelopment  of  the  walls  of  the  body 
or  of  an  organ.  Example :  Of  the  rectovaginal  septum,  resulting 
in  rectovaginal  fistula.    These  are  comparatively  rare. 

2.  Traumatic  :  Penetrating  wounds,  or  severe  pressure  ex- 
tending from  the  skin  or  mucous  membrane  to  one  of  the  ducts 
or  cavities.  Examples,  (a)  involving  the  parotid  duct,  causing 
salivary  fistula  opening  on  the  cheek;  (6)  between  the  vagina 
and  bladder,  from  pressure  or  injury  at  confinement,  resulting 
in  vesicovaginal  fistula;  (c)  rectovaginal  fistula  resulting  from 
incomplete  healing  of  an  obstetrical  laceration  of  the  perineum 
into  the  rectum. 

3.  Necrotic  or  inflammatory,  extension  of  an  abscess  to 
both  surfaces  of  adjacent  organs.     Examples,  of  a   perirectal 


COMMON  TYPES  OF  LOCAL  INFECTIONS       21 

abscess  into  the  rectum  and  also  to  the  skin  of  the  perineum. 
A  "fecal  fistula,"  resulting  from  the  breaking  down  of  a  necrotic 
caecum  into  an  appendectomy  wound.  Ulceration  and  extension 
of  a  malignant  new-growth.  Example,  cancer  of  the  cervix  of 
the  uterus  into  the  bladder. 

4.  Therapeutic  or  surgical  fistula.  Examples:  (a) 
Cholecystostomy,  drainage  of  the  gall-bladder  or  fistula  forma- 
tion, which  is  done  for  drainage  of  the  infected  bile  to  the 
surface  of  the  body.  (6)  Gastrostomy,  an  artificial  opening  into 
the  stomach,  is  made  for  feeding  when  there  is  an  impassable 
obstruction  of  the  oesophagus,  (c)  Colostomy,  opening  into  the 
large  intestine,  is  made  to  provide  an  artificial  anus  for  drainage 
when  there  is  a  permanent  obstruction  in  the  lower  bowel  or 
rectum. 

A  fistula  is  characterized  by  copious  discharge  of  contents 
from  the  cavity  with  which  it  communicates,  thus  preventing 
any  tendency  to  spontaneous  closure,  and  requires  frequent 
change  of  dressings  or  the  use  of  special  apparatus.  Persistence 
of  certain  types  of  fistula  is  the  rule,  and  there  is  no  tendency 
to  spontaneous  closure  where  one  or  both  of  the  following 
factors  are  present:  (a)  The  fistulous  tract  may  be  lined  with 
epithelium  or  an  infected  granulating  surface,  which  prevents 
spontaneous  healing.  (5)  There  is  partial  or  complete  obstruc- 
tion to  the  normal  outlet  of  the  organ  involved  and  its  secretions 
or  contents  overflow  through  the  fistula,  thus  maintaining  the 
opening.  Cure  is  spontaneous  in  many  types  when  the  condi- 
tion is  of  short  duration  and  there  is  no  obstruction  to  normal 
emptying  of  the  organ  in  question.  Surgical  cure,  to  be  success- 
ful, requires  (a)  that  any  obstruction  to  the  normal  outlet  be 
removed;  (6)  that  the  fistulous  tract  be  excised;  (c)  that  the 
wall  of  the  organ  be  closed  separately  from  the  surface,  and,  if 
possible,  that  one  or  more  layers  of  tissue  or  fascia  be  interposed. 

D.  An  ulcer  is  a  superficial  ^necrosis  of  surface  epithelium 
associated  with  infection  and  local  inflammation.  The  effects 
may  be  entirely  local,  or  the  ulcer  sometimes  serves  as  the 
portal  of  entry  for  serious  general  infection,  with  constitutional 
effects.    Example,  typhoid  fever. 

The  CAUSES  are: 

1.  Destruction  of  the  surface  epithelium  by  (a)  injury,  irri- 
tation or  burns;  (6)  infection  from  pathogenic  organisms  on  the 


22        ESSENTIALS  OF  SURGERY  FOR  NURSES 

surface  or  carried  to  the  area  by  the  blood  stream;  there  is 
predisposition  to  local  infection  on  account  of  the  necrotic  or 
devitalized  tissue  cells;  (c)  breaking  down  of  superficial  tumors 
or  new-growths,  due  to  pressure  and  necrosis  of  the  overlying 
epithelium.  This  occurrence  always  suggests  the  possibility  of 
malignancy  in  the  tumor,  and  is  an  indication  for  adequate 
surgical  treatment. 

2.  Predisposing  causes  are:  (a)  Local:  (i)  Deficient  blood 
supply  normally.  Ulcers  are  more  frequent  and  persistent  in 
regions  which  have  a  relatively  poor  blood  supply  (anterior 
tibial  surface),  (ii)  In  regions  where  the  blood  supply  is  deficient 
because  of  local  disease  or  accident,  local  arteriosclerosis  or 
varicose  veins,  (iii)  Defective  nerve  supply  and  loss  of  "tone." 
Example:  bed-sores  and  ulcers  in  parts  which  are  paralyzed, 
especially  in  case  of  injury  to  the  spinal  cord.  (6)  General:' 
Constitutional  disease :  syphilis,  diabetes,  arteriosclerosis,  severe 
malnutrition  or  cachexia.  In  such  condition  healing  of  slight 
superficial  injuries  is  slow  and  incomplete.  Resistance  to  invad- 
ing pathogenic  bacteria  is  low,  therefore  local  infection  of  the 
wound  or  ''ulceration"  follows. 

Location. — Ulcers  may  be  found  on  any  epithelial  surface, 
i.e.,  skin  or  mucous  membrane,  especially  in  regions  exposed  to 
irritation  and  infection.  They  are  more  persistent  in  regions 
where  resistance  is  normally  low  or  is  impaired  by  pathologic 
changes.  Example:  the  mouth  irritated  by  carious  teeth,  the 
stomach  by  the  acid  gastric  juice.  Low  local  resistance  of  the 
leg  on  account  of  the  poor  venous  circulation  is  often  increased 
pathologically  by  varicose  veins  or  constitutional  disease.  As 
a  result,  minor  injuries  with  slight  destruction  of  tissue,  instead 
of  healing  promptly ,  become  infected,  form  open  ulcerations, 
and  resist  ordinary  local  treatment. 

Types  op  Ulcers. — Varicose  ulcer,  on  the  leg,  associated 
with  varicose  veins.  Syphilitic  ulcers  resulting  from  broken 
down  gummas  tend  to  extend  at  the  periphery  in  spite  of  local 
treatment.  Gangrenous  ulcers,  associated  with  low  resistance, 
prolonged  infections  and  virulent  bacteria,  spread  rapidly, 
with  marked  tissue  destruction.  Malignant  ulcers,  due  to 
breaking  down  of  the  epithelium  over  superficial  malignant 
new-growths. 

Course   of  Healing. — A  wound  with   superficial   tissue 


COMMON  TYPES  OF  LOCAL  INFECTIONS       23 

destruction  heals  normally  in  a  definite  manner.     There  are 
three  stages  : 

1.  Tissue  which  has  been  destroyed  is  thrown  off  or  sloughs. 
This  process  may  take  several  days  and  the  necrotic  tissue  is 
easily  infected.  The  superficial  wound  opens  channels  for  the 
spread  of  infection  in  tissue  spaces,  and  the  absorption  of 
toxins.  Hence  an  ulcer  is  truly  a  localized  infection  or  portal 
of  entry.  Toxic  symptoms  are  usually  mild  and  extension  is 
not  marked,  since  the  process  is  superficial  and  there  is  free 
drainage.  Danger  of  pockets  and  scab  formation:  When  the 
surface  is  covered  or  there  are  deep  cavities  with  overhanging 
edges,  the  process  comes  to  resemble  true  cellulitis  or  abscess, 
extends,  and  causes  constitutional  effects. 

2.  The  development  of  granulation  tissue  over  the  base  and 
at  the  edges  of  an  ulcerating  surface  serves  two  purposes:  (a) 
Limits  the  extension  of  the  infection  and  prevents  the  absorption 
of  toxins;  (6)  fills  in  the  space  left  by  destruction  of  tissue  and 
aids  in  the  healing  process. 

3.  New  epithelium  develops  at  the  edges  and  grows  toward 
the  centre  as  the  granulation  tissue  reaches  the  surface.  This 
extension  of  epithelium  is  retarded  as  long  as  the  surface  is 
infected,  or  is  often  further  delayed  by  excessive  development  of 
exuberant  granulations,  "proud  flesh,"  which  project  above  the 
surface  and  prevent  the  overgrowth  of  epithelium  from  the 
edges.  Any  undue  delay  in  the  progress,  with  persistence  of 
an  open  infected  area  or  ulcer,  is  usually  due  to  some  of  the 
predisposing  causes. 

Complications  and  Sequels. — 1.  Scab-formation  over  the 
surface,  or  the  extension  of  an  ulceration  under  the  edges,  results 
in  absorption  of  toxins  with  constitutional  symptoms  and  fur- 
ther spread  of  the  local  process.  It  is  obvious  that  such  cavities 
should  be  promptly  opened,  overhanging,  necrotic  flaps  removed, 
and  free  drainage  secured. 

2.  Persistent  Infected  Granulations. — ^As  the  result  of  various 
predisposing  causes,  the  granulation  surface  on  the  floor  of  an 
ulcer  shows  no  tendency  to  heal  over,  becomes  non-vascular, 
Mdth  a  purulent  discharge.  In  such  cases  it  may  be  necessary 
to  remove  the  surface  infected  granulations  by  curetting  or 
cauterizing  down  to  healthy  tissues,  and  to  treat  the  particular 
predisposing  factors. 


24        ESSENTIALS  OF  SURGERY  FOR  NURSES 

3.  Cicatricial  contraction  and  deformity  occur  in  certain 
types  of  ulcers  with  extensive  loss  of  tissue,  especially  burns 
of  the  sldn  or  ulcers  of  the  hollow  organs,  oesophagus,  stomach 
or  intestine.  These  latter  often  cause  constriction  of  the  lumen, 
occasionally  leading  to  an  impermeable  "stricture."  Suitable 
plastic  operations  or  anastomoses  between  the  hollow  organs 
are  often  necessary  to  correct  the  condition. 

4.  Malignant  growth  in  an  ulcer  is  important  from  two 
standpoints:  (a)  The  condition  may  be  malignant  from  the 
start;  in  other  words,  a  superficial  malignant  growth  becomes 
evident  as  an  open  ulcer  which  extends  in  spite  of  the  ordinary 
treatment.  A  superficial  tumor  (mole,  or  wart),  which  becomes 
ulcerated^  must  be  regarded  as  malignant,  and  excised  without 
delay.  Therefore  an  ulceration  which  resists  local  treatment 
and  with  no  adequate  predisposing  cause  should  be  regarded 
as  malignant  and  so  treated,  i.e.,  excised,  and  a  suitable  plastic 
operation  done.  (6)  Malignant  degeneration  in  the  healing  of 
certain  chronic  ulcers  is  claimed  to  occur  as  a  result  of  atypical 
epithelial  development.  The  relative  importance  of  this  possi- 
bility cannot  be  discussed  in  detail,  but  it  must  always  be  kept 
in  mind  in  the  case  of  certain  chronic  ulcers.  Examples,  those 
of  the  stomach,  also  those  of  the  skin  resulting  from  X-ray 
burns. 

Treatment. — This  must  meet  two  indications,  (1)  the 
local  condition;  (2)  the  particular  predisposing  cause. 

1.  Local  treatment  is  limited  to  ulcers  of  the  skin  and  is 
considered  under  four  heads :  (a)  To  provide  healthy  tissues  for 
healing  by  granulation;  (6)  to  prevent  or  overcome  infection; 

(c)  to  avoid  all  irritation  and  injury  to  developing  epithelium; 

(d)  to  correct  deformity. 

(a)  As  a  preliminary,  the  local  lesion  must,  as  far  as  possible, 
be  brought  to  the  condition  of  an  open  wound  in  healthy  tissues, 
to  allow  normal  wound  healing  by  granulation.  The  surface  is 
thoroughly  exposed,  necrotic  tissue  removed,  cavities  and 
pockets  opened,  and  free  drainage  provided. 

(6)  and  (c)  To  overcome  and  prevent  infection,  local  dress- 
ings of  mild  antiseptics,  moist  compresses,  dusting  powders,  or 
ointments  are  used.  These  should  also  prevent  irritation  from 
dressings  and  stimulate  the  formation  of  granulation  tissue, 
and  the  overgrowth  of  epithelium  from  the  edges.    Exuberant 


COMMON  TYPES  OF  LOCAL  INFECTIONS        25 

granulations,  "proud  flesh,"  at  times  interfere  with  epithelial 
development  and  may  have  to  be  removed  by  cauterization  or 
the  curette.  Open  air  treatment  with  suitable  protection  from 
the  clothes  often  stimulates  rapid  healing, 

(d)  Deformities  from  contraction  of  scar  tissue  often  requires 
special  plastic  operation. 

2.  Treatment  of  the  particular  predisposing  causes  is  often 
the  more  important  part  of  the  procedure.  It  may  include 
(a)  increasing  the  local  blood  supply  by  hot  air,  hot  moist 
dressings,  or  massage;  (6)  overcoming  venous  stasis;  elevation 
of  a  limb,  rest  in  bed,  special  bandage,  or  radical  cure  of  varicose 
veins;  (c)  special  treatment  of  constitutional  disease — syphilis, 
diabetes,  heart  or  kidney  conditions,  or  malnutrition. 

E.  Gangrene  refers  to  the  destruction  or  necrosis  of  a  part 
of  the  body  "en  masse."  Example,  a  toe,  limb  or  organ,  usually 
as  a  result  of  partial  or  complete  interference  T^dth  the  arterial 
blood  supply  to  the  part  involved. 

The  CAUSES  are  (1)  local;   (2)  indirect;    (3)  constitutional. 

1.  Local. — (a)  Crushing  or  lacerated  wounds;  (b)  continued 
pressure  resulting  in  actual  tissue  destruction;  (c)  devitalization 
to  a  point  where  resistance  to  infection  is  lost  and  necrosis 
follows,  or  (d)  separation  of  extensive  flaps  or  parts  from  an 
adequate  blood  or  nerve  supply. 

2.  Indirect. — Interference  with  the  normal  blood  and  nerve 
supply  by  (a)  ligation  of  the  chief  artery  to  a  part  on  account 
of  hemorrhage;  (6)  local  disease  of  the  artery  (arteriosclerosis) 
narrowing  or  occluding  its  lumen;  (c)  tight  bandage,  cast,  or 
tourniquet,  interfering  with  the  blood  and  nerve  supply  for  a 
continued  period. 

3.  Constitutional  disease,  resulting  in  arterial  thickening 
involving  certain  arteries,  cutting  off  the  blood  supply  to  one  or 
more  extremities.  These  diseases  include  arteriosclerosis, 
diabetes,  and  certain  remote  conditions  of  the  nervous  system, 
Raynaud's  disease,  locomotor  ataxia,  and  "tone"  (vasomotor 
control)  in  the  tissues  which  interfere  with  the  normal  nerve- 
supply  of  dependent  regions,  especially  the  extremities. 

Types. — Two  forms  of  gangrene  are  described:  1.  Moist 
gangrene,  which  occurs  as  the  result  of  a  sudden  blocking  of 
the  arterial  blood  supply,  most  often  associated  with  crushing 
injuries.    The  part  involved  contains  fluid,  blood  and  lymph, 


26        ESSENTIALS  OF  SURGERY  FOR  NURSES 

and  the  tissues  are  therefore  moist.  Infection,  particularly  with 
the  "gas  bacillus,"  and  sepsis  are  more  frequent  and  early  in 
this  form  of  gangrene. 

2.  Dry  gangrene,  the  more  common  form,  is  the  result  of 
gradual  interference  with  the  principal  blood  supply  to  a  part. 


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Example:  arteriosclerosis,  causing  gradual  obliteration  of  the 
lumen  of  an  artery.  The  most  dependent  parts,  2. e. ,  toes,  are  first 
involved,  and  the  process  spreads  slowly  till  it  reaches  a  region 
where  the  circulation  is  adequate.  "Collateral  circulation"  (see 
anatomy)  is  provided  by  anastomoses  between  various  branches 
given  off  from  the  principal  artery  at  different  levels,  and  fur- 
nishes a  reserve  blood  supply  to  most  regions  (Fig.  5).  This  is 
rarely  adequate  when  the  main  artery  is  suddenly,  completely 
occluded,  but  will  develop  to  a  varying  degree,  and  may  com- 
pensate for  gradual  occlusion,  preventing  extensive  gangrene. 
Infection  is  a  constant  danger  in  dry  gangrene  but  is  not  so 


COMMON  TYPES  OF  LOCAL  INFECTIONS       27 

urgent  as  is  the  case  with  the  moist  form,  and  radical  treatment 
is  often  delayed  to  determine  the  extent  of  the  co-lateral 
circulation. 

Course  and  Symptoms. — Moist  gangrene  is  evident  from 
the  beginning  by  the  appearance  of  the  tissues,  which  are 
swollen,  dark,  and  rapidly  undergo  decomposition  as  a  result 
of  infection.  Prompt  radical  removal  of  such  gangrenous 
structures  is  urgently  indicated  to  avoid  sepsis.  Dry  gangrene 
causes  more  or  less  characteristic  premonitory  changes  and 
symptoms:  L  A  peculiar  numbness  and  tingling,  and  loss  of 
sensation  is  often  noted  months  before  actual  gangrene  is 
present.  2.  Coldness  and  poor  circulation.  After  light  pressure 
is  applied  to  the  skin  and  suddenly  removed,  the  return  of  the 
normal  pink  color  is  delayed.  The  part  chills  easily  and  does 
not  perspire  freely;  pulsation  in  the  arteries  is  less  evident. 
The  more  dependent  parts  gradually  turn  dark,  finally  black, 
and  gangrene  is  complete.  The  process  extends  upward  to  a 
varying  extent  and  finally  develops  a  definite  line  of  demarcation 
between  the  gangrenous  tissues  and  those  which  possess  an 
adequate  blood  supply.  It  is  possible  for  the  entire  process  to 
go  on  as  an  aseptic  one  and  for  the  gangrenous  part  to  separate 
or  "slough,"  resulting  in  a  "spontaneous  amputation."  Surgical 
amputation  is  advised  as  soon  as  a  line  of  demarcation  has 
developed  to  avoid  the  danger  of  sepsis.  This  is  done  in  healthy 
tissues  at  certain  points  of  election  where  the  blood  supply  is 
sufficient  to  nourish  the  flaps  and  secure  healing  by  first  intent. 

Treatment.  L  Prophylactic. — (a)  Avoid  the  ligation  of  the 
principal  artery  to  a  part,  if  possible.  (6)  If  this  is  necessary, 
or  gangrene  is  already  threatening,  elevation  of  the  part,  hot 
air,  massage,  and  measures  to  improve  the  circulation,  (c) 
Treatment  of  the  particular  underlying  constitutional  disease. 
(d)  Aseptic  care  of  the  gangrenous  parts  to  prevent  infection. 
2.  Surgical  Treatment.— Aunpxitation  is  indicated  to  remove  dead 
tissue,  which  is  a  source  of  danger  to  the  individual  from  sepsis. 

E.  Freezing  and  bums  cause  local  destruction  of  tissues. 

Freezing,  from  exposure  to  excessive  cold,  causes  a  paralysis 
of  the  circulation  and  congealing  of  the  fluids  in  the  tissues. 
If  the  area  involved  is  extensive,  and  has  been  exposed  to  a  low 
temperature  for  a  long  period,  gangrene  results  before  the  cir- 
culation can  be  re-established,  and  amputation  is  necessary. 


28        ESSENTIALS  OF  SURGERY  FOR  NURSES 

In  milder  cases,  only  the  superficial  layers  of  skin  are  involved, 
the  surface  blisters  and  peels,  while  there  is  a  marked  painful 
compensatory  congestion  and  swelling  of  the  deeper  structures. 

Treatment  aims  to  re-establish  the  circulation  and  body 
temperature  of  the  part  gradually.  This  is  done  with  friction, 
rubbing  or  massage,  usually  with  snow  or  ice,  and  later  soothing 
lotions  to  relieve  pain.  For  the  severe  cases  stimulants  are 
indicated  to  overcome  depression,  and  later  amputation  of 
parts  which  become  gangrenous. 

Burns  are  caused  by  fire,  boiling  water,  live  steam,  certain 
chemicals,  electricity,  and  the  X-ray.  We  are  chiefly  concerned 
with  those  due  to  fire,  boiling  water  or  live  steam,  and  these  are 
usually  classed  as: 

First  degree  hums,  characterized  by  redness  of  the  skin  and 
but  Httle  destruction  of  tissue.  They  are  painful,  but  there  is 
no  scarring  or  contraction  of  tissue  in  healing. 

Second  degree  hums  cause  blebs  and  blisters  on  the  surface, 
are  very  painful,  and  easily  infected,  so  that  healing  may  be 
slow.  There  is  no  extensive  tissue  destruction,  and  no  deforming 
scars  or  serious  contractures. 

Third  degree  hums  include  all  in  which  there  is  actual  destruc- 
tion of  tissue  up  to  the  point  where  a  part  is  entirely  destroyed. 
In  all  of  these,  especially  when  the  muscles  and  tendons  are 
involved,  there  result  deforming  contractures  from  scar  tissue 
in  healing. 

Effects  are  (1)  local,  as  already  considered;  (2)  general  or 
constitutional:  (a)  pain,  (6)  shock,  and  (c)  toxaemia,  all  of 
which  vary  with  the  extent,  rather  than  the  degree  of  the  burning. 
It  is  usually  stated  that  a  burn  which  involves  one-third  or 
more  of  the  surface  of  the  body  is  fatal.  Pain  is  severe  on 
account  of  the  exposed  nerve  endings,  and  often  causes  a  high 
degree  of  shock  which  may  be  fatal.  Toxaemia,  resulting  in 
kidney  lesions,  may  cause  death  after  some  days.  This  tox- 
aemia is  not  clearly  understood,  but  is  often  a  most  serious 
complication. 

Treatment.  General. — Opium  or  morphine  is  indicated  in 
amounts  sufficient  to  relieve  pain  and  prevent  shock. 

Local  Treatment. — (a)  To  relieve  pain  from  irritation,  an 
oily  dressing,  "carron  oil"  (linseed  oil  and  lime  water),  solutions 
of  picric  acid,  mild  oily  antiseptics,  boric  acid  ointment  to  avoid 


COMMON  TYPES  OF  LOCAL  INFECTIONS        29 

infection,  (h)  To  promote  healing,  open  air  treatment  is  advo- 
cated, (c)  To  correct  deformity  from  contraction  of  cicatricial 
tissue,  suitable  plastic  operations  are  necessary.  ^ 

In  the  local  treatment  of  burns,  one  must  avoid  all  unneces- 
sary disturbance  or  handling.  As  early  as  possible,  trim  off  all 
blebs  and  blisters  to  prevent  infection  from  extending  under 
the  epidermis. 

The  use  of  mixtures  of  melted  paraflan  apphed  with  a  special 
apparatus  has  recently  been  extensively  popularized.  It  pre- 
vents painful  irritation  of  the  sensitive  exposed  tissue,  and  is 
said  to  promote  rapid  healing  with  a  minimum  of  scar  tissue. 

The  conditions  described  in  the  preceding  pages  will  be 
more  clearly  appreciated  if  it  is  possible  to  demonstrate  certain 
typical  cases,  or  at  least  to  study  the  case  histories  together 
with  the  operative  notes  and  other  data. 

DEMONSTRATIONS 

1.  Psoas  abscess  with  Rontgen  ray  plate  showing  tuberculosis  of  spine. 

2.  Perirectal  abscess  and  sinus  injected  with  bismuth  and  Rontgen  ray 

plate  or  picture. 

3.  Various  types  of  fistula. 

4.  Leg  ulcers. 

5.  Ulceration  of  malignant  growth. 

6.  Case  of  gangrene,  with  history. 

7.  Various  types  of  burns,  electric  and  Rontgen  ray. 

8.  Scar  tissue  contraction  and  deformity. 

9.  Demonstration  of  "first  aid"  methods  and  apparatus,  especially  that 

for  paraffin  treatment. 


CHAPTER  III 

EFFECTS  OF  SPECIFIC  PATHOGENIC  BACTERIA 

Two  types  of  infectious  processes  are  described : 

Acute  infections,  which  are  characterized  by  a  sudden  onset, 
severe,  rapidly  increasing  symptoms,  a  short  course,  with  marked 
toxaemia  and  constitutional  effects.  There  is  either  an  early 
fatal  outcome  or  a  fairly  rapid  recovery,  after  a  more  or  less 
definite  "crisis,"  after  which  time  it  is  evident  that  the  infectious 
organisms  have  been  overcome.  The  classical  example  of  an 
acute  infection  is  lobar  pneumonia,  but  certain  surgical  lesions 
belong  to  the  same  type,  at  least  as  regards  onset,  and  recovery, 
after  suitable  surgical  procedure,  is  prompt  and  complete.  Ex- 
amples, acute  osteomyelitis,  appendicitis,  or  certain  abscesses. 

Chronic  infections  refer  to  certain  conditions  which  are  more 
gradual  in  their  onset  and  course.  The  constitutional  effects 
are  less  violent,  but  are  quite  definite  and  may  increase  progress- 
ively to  a  fatal  outcome.  Tuberculosis  represents  the  most 
characteristic  of  the  chronic  processes,  but  the  term  includes 
almost  any  infection  which  extends  over  a  long  period  of  time. 

Infectious  processes  call  for  surgical  interest:  (a)  When 
they  present  a  local  lesion  which  can  advantageously  be  removed, 
excised  (acute  appendicitis),  or  opened  and  drained,  incised 
(osteomyelitis).  (6)  When  there  are  superficial  ulcers,  sinuses, 
fistulse,  strictures,  or  deformities  to  be  treated,  (c)  Certain  of 
the  specific  infectious  fevers  (typhoid)  which  cause  conditions 
demanding  surgical  treatment,  or  which  cause  complications  in 
post-operative  recovery,  are  of  interest. 

The  diagnosis  of  the  specific  pathogenic  organisms  which 
are  causing  a  particular  infection  is  important  (a)  to  determine 
the  methods  of  treatment,  particularly  if  vaccines  are  to  be  used; 
(6)  for  the  production  of  autogenous  vaccines;  (c)  for  prognosis. 

Methods  of  diagnosis  include  many  technical  laboratory 
details : 

1.  Microscopical  examination  of  stained  smears  of  blood,  or 

discharge. 
30 


SPECIFIC  PATHOGENIC  BACTERIA  31 

2.  Laboratory  study  of  "cultures"  from  discharge,  or 
blood,  made  on  special  media.  "Pure  cultures"  are  obtained 
when  but  a  single  organism  is  present. 

3.  Animal  inoculations.  When  it  is  not  possible  to  isolate 
the  causal  pathogenic  bacteria,  some  of  the  septic  material, 
pus  or  blood,  is  injected  into  laboratory  animals  (guinea-pigs). 
The  resulting  lesions  are  more  or  less  typical  of  certain  infections, 
or  the  organisms  can  be  isolated  from  them. 

Mixed  Infections. — This  term  is  applied  when  two  or  more 
pathogenic  organisms  are  isolated  from  a  single  infectious 
process.  Examples:  Diphtheria  and  streptococcus  from  a 
throat;  B.  coli  and  staphylococcus  from  an  abscess. 

Secondary  infections  occur  in  a  local  lesion,  as  a  result  of 
contamination  from  the  surface  through  a  sinus  or  drainage, 
also  rarely  from  an  adjacent  septic  cavity.  Example:  A  dis- 
charging tubercular  abscess  often  becomes  infected  by  staphy- 
lococci or  B.  coli  from  the  surface. 

A  few  of  the  more  common  pathogenic  organisms  which 
cause  surgical  lesions  will  be  considered  in  respect  to  their 
particular  effects. 

A.  Staphylococci,  of  which  there  are  several  varieties,  are 
found  normally  on  the  skin,  in  the  various  orifices  of  the  body, 
the  intestinal  tract,  and  lower  genital  tract. 

The  LOCAL  LESIONS  include  skin  abscesses,  pimples,  pus- 
tules, carbuncles,  wound  infections,  and  certain  types  of  puer- 
peral sepsis.  The  organisms  are  found  as  secondary  invaders  in 
sinuses  and  fistulse.  There  is  nothing  characteristic  about  the  lo- 
cal process  except  that  suppuration  and  pus  production  is  profuse. 

The  CONSTITUTIONAL  EFFECTS  are  comparatively  slight 
except  in  individuals  whose  resistance  is  very  low,  and  in  long 
standing  chronic  processes. 

Principles  of  treatment  include  (1)  free  incision  and  drainage, 
or  that  of  special  lesions,  sinuses  or  fistulse;  (2)  constitutionally, 
measures  to  increase  the  bodily  resistance.  In  certain  chronic 
infections,  autogenous  vaccines  are  used. 

B.  Streptococci. — These  organisms  seem  to  vary  greatly  in 
virulence  and  in  their  effects.  Distribution  on  the  skin,  in  the 
throat,  intestinal  tract,  and  accidentally  in  other  regions. 
Strains  of  virulent  organisms  seem  to  be  transmitted  easily 
from  one  individual  to  another,  or  from  discharges 


32        ESSENTIALS  OF  SURGERY  FOR  NURSES 

The  LOCAL  LESION  is  characterized  by  marked  redness 
and  sweHing,  though  there  is  but  shght  tissue  destruction  or 
suppuration. 

1.  Tonsils  and  Throat:  Acute  tonsillitis  and  pharyngitis, 
besides  the  local  inflammation,  cause  severe  general  symptoms 
— fever,  toxaemia,  and  prostration.  Often  there  are  more  remote 
effects  or  sequels  (endocarditis  or  acute  rheumatism)  which 
persist,  or  recur,  at  least  till  the  infected  tonsils  are  removed. 
2.  Skin:  Erysipelas  occurs  as  a  wound  infection,  or  spontane- 
ously in  an  unbroken  skin,  particularly  of  the  face.  The  tissues 
are  red,  swollen  and  painful,  though  suppuration  is  rare.  The 
constitutional  effects  are  severe,  but  recovery  is  usual.  3. 
Puerperal  sepsis,  when  caused  by  virulent  streptococci,  is  serious, 
with  a  high  mortahty.  4.  Intestinal  tract,  certain  surgical 
lesions  (appendicitis,  or  peritonitis),  when  due  to  streptococcus, 
give  rise  to  characteristic  general  reaction. 

The  CONSTITUTIONAL  EFFECTS  are  severe,  with  chills,  high 
fever,  marked  toxaemia,  due  to  toxins  absorbed  from  the  local 
lesion.  The  pathogenic  organisms  can  be  isolated  from  the 
circulating  blood  in  the  more  advanced  forms  of  this  infection, 
in  which  case  the  prognosis  is  unfavorable. 

Treatment,  locally,  is  surgical,  if  possible,  with  free  drainage 
and  antiseptic  compresses.  Constitutional  measures  include 
elimination  of  toxins,  combating  toxaemia,  and  in  some  in- 
stances, "antistreptococcic  serums." 

C.  Gonococcus. — These  organisms  are  found  in  the  discharge 
from  local  lesions,  or  articles  which  have  been  contaminated  by 
such  discharge.  Portals  of  Entry:  Two  regions  of  the  body 
seem  to  be  particularly  sensitive  to  invasion  by  this  organism: 
(1)  the  urethra  and  mucous  membrane  of  the  vagina,  cervix, 
and  uterus;  (2)  the  conjunctiva,  especially  of  the  new-born. 

1.  GoNORRHCEAL  URETHRITIS,  or  VAGINITIS,  is  usually  the 
result  of  venereal  exposure,  though  it  may  be  acquired  inno- 
cently from  contaminated  articles,  towels  or  instruments.  The 
latter  method  is  particularly  important  in  children's  wards, 
where  the  patients  are  often  poorly  nourished.  The  process 
especially  in  adults  extends  rapidly  to  the  cervix  and  endome- 
trium of  the  uterus,  or  the  Fallopian  tubes,  where  it  usually 
becomes  chronic.  The  surgical  lesions  resulting  are  (a)  abscess 
of  Bartholin's  gland  in  the  labia  majora;   (b)   peri-urethral 


SPECIFIC  PATHOGENIC  BACTERIA  33 

abscess;  (c)  chronic  cervicitis  and  endometritis;  {d)  salpingitis, 
inflammation  of  the  Fallopian  tubes,  and  pelvic  peritonitis. 
Constitutional  effects  are  mild  in  the  early  cases,  though  there 
is  moderate  prostration  and  fever  in  the  severe  forms,  especially- 
pelvic  peritonitis,  where  there  is  also  marked  local  pain  and 
tenderness. 

Treatment. — Locally,  this  varies  with  the  form  of  the  lesion. 
Drainage  is  provided  for  infected  surfaces,  and  local  applications 
or  irrigations  are  used.  Abscesses  are  incised,  if  superficial,  or 
when  there  is  danger  of  spontaneous  rupture.  In  other  cases 
they  are  allowed  to  become  chronic,  when  the  encapsulated 
mass  can  be  enucleated  intact. 

2.  GoNOERHCEAL  CONJUNCTIVITIS. — (a)  In  the  adult  the 
infection  is  caused  by  septic  material  from  gonorrhoeal  discharge 
reaching  the  conjunctiva.  The  local  lesion  is  a  purulent  inflam- 
mation of  the  delicate  conjunctival  membrane,  causing  a  profuse 
discharge.  The  course  is  rapid  and  ulcers  develop  which  destroy 
the  cornea  over  the  pupil,  or  produce  opacities  in  this  structure 
resulting  in  blindness.  The  diagnosis  is  made  from  stained 
smears.  The  treatment  is  essentially  local  and  consists  of  instilla- 
tions of  strong  silver  preparations,  silver  nitrate  or  argyrol,  and 
frequent  irrigation  with  mild  antiseptics,  boracic  acid  solution. 

(6)  In  the  new-born,  the  infection  (ophthalmia  neonatorum) 
occurs  at  birth  from  septic  secretions  of  the  mother's  birth 
canal,  and  the  course  is  rapidly  destructive  on  account  of  the 
low  resistance  of  the  delicate  conjunctiva.  The  disease  is  the 
most  frequent  cause  of  blindness  in  the  new-born.  Treatment. — 
Prophylactic,  is  the  routine  instillation  of  a  silver  preparation 
into  the  conjunctiva  immediately  after  birth,  which  effectively 
prevents  the  infection.  It  is  much  better  to  treat  nine  cases  in 
this  manner  unnecessarily  than  to  miss  one  which  is  exposed  to 
infection.  The  diagnosis  and  treatment  are  similar  to  that  in 
the  adult,  but  it  must  be  prompt  and  vigorous. 

D.  Other  forms  of  cocci  rarely  cause  surgical  lesions.  The 
pneumococcus  is  sometimes  found  in  pleurisy  with  effusion,  or 
empyema,  and  less  often  in  certain  forms  of  peritonitis,  charac- 
terized by  marked  and  severe  constitutional  effects. 

E.  Typhoid  bacilli  are  found  in  water  and  foods  which  are 
contaminated  directly  or  indirectly  with  excreta  of  individuals 
infected  with  the  organism.    The  "portal  of  entry"  is  usually 

3 


34        ESSENTIALS  OF  SURGERY  FOR  NURSES 

an  ulceration  of  the  small  intestine,  and  the  constitutional 
effects  are  characteristic.  In  its  typical  form,  the  disease  is 
essentially  a  medical  condition,  and  surgical  interest  is  limited 
to  certain  complications  or  sequelse:  1.  An  ulcer  may  perforate 
the  wall  of  the  intestine,  causing  a  rapidly  spreading  general 
peritonitis  which  is  fatal  unless  surgical  drainage  is  promptly 
provided.  2,  Gall-bladder  infections,  cholecystitis  occurring 
either  as  a  complication  or  sequel  of  the  disease,  require  proper 
surgical  intervention.  3.  Local  abscesses  may  complicate  and 
require  adequate  incision  and  drainage. 

F.  B.  Coli. — This  organism  is  found  normally  in  the  intestinal 
tract.  It  causes  infection  and  suppuration  in  lesions  of  that 
tract  or  adjacent  to  it.  Examples,  appendicitis,  peritonitis, 
perirectal  abscess.  Suppuration  is  profuse  and  the  odor  of 
the  discharge  is  characteristically  fecal,  at  times  to  a  degree 
which  leads  the  surgeon  to  suspect  a  fecal  fistula  when  none 
exists.  The  constitutional  effects  are  not  characteristic,  and  the 
treatment  does  not  differ  from  that  of  similar  processes  caused 
by  other  organisms. 

G.  Tetanus  bacilli  are  contained  in  the  excreta  of  horses  and 
stock,  and  are  therefore  most  often  found  in  stable  and  street 
dirt,  or  fertihzed  soil.  The  "portal  of  entry"  is  usually  an 
accidental  wound  contaminated  by  the  above  mentioned  ma- 
terial. The  organism  is  anaerobic,  therefore  grows  best  in  the 
depth  of  a  punctured  wound,  remote  from  the  surface,  with 
poor  drainage.  The  presence  of  blood  or  necrotic  material  is 
favorable  to  its  active  development. 

Effects. — 1.  Local  effects  are  often  delayed  for  from  six  to 
fifteen  days,  and  there  is  comparatively  little  suppuration  or 
tissue  destruction.  2.  Constitutional  disturbances  are  due  to 
the  absorption  of  soluble  toxins  produced  by  the  bacteria. 
These  poisonous  substances  reach  the  central  nervous  system, 
probably  by  way  of  the  peripheral  nerves,  causing  painful 
'Honic"  (i.e.,  continuous)  contraction  of  the  voluntary  muscles, 
which  is  usually  first  evident  in  the  muscles  of  the  neck  and 
those  of  mastication,  which  explains  the  common  term  "lock- 
jaw." Other  muscle  groups  are  later  involved  and  the  patient 
eventually  dies  of  exhaustion  from  pain,  sleeplessness,  and  from 
starvation. 

Treatment. — 1.  Prophjdactic :     Includes  care  of  accidental 


SPECIFIC  PATHOGENIC  BACTERIA  35 

wounds,  free  exposure  of  the  wound,  evacuation  of  necrotic 
material,  irrigation  with  oxidizing  agents  (peroxide  of  hydrogen 
or  permanganate  of  potash)  and  of  drainage  to  prevent  the 
formation  of  pockets  or  the  development  of  bacterial  activity 
remote  from  the  surface.  The  same  treatment  of  the  local 
wound  is  indicated  later,  should  constitutional  symptoms  of  the 
disease  develop.  2.  Specific:  Injection  of  antitetanic  serum 
or  antitoxin.  This  should  be  used  as  a  prophylactic  measure 
at  the  first  dressing  of  all  suspicious  accidental  wounds.  By 
this  means  constitutional  symptoms  are  effectually  prevented. 
Otherwise,  when  general  effects  are  evident,  the  chances  of 
overcoming  the  infection  are  decreased,  and  larger  doses  of 
serum  are  needed.  3.  Medical  treatment  includes  (a)  measures 
to  relieve  pain  and  muscle  rigidity — morphine,  chloral  hydrate, 
or  other  hypnotics;  also  the  use  of  substances  (magnesium  sul- 
phate) injected  into  the  spinal  canal  by  ''lumbar  puncture"; 
(b)  supplying  fluids  and  nutrition  by  stomach  tube,  proctoclysis, 
or  enema. 

H.  Bacillus  of  Malignant  (Edema,  "  Gas  Bacillus."— The 
distribution  is  much  the  same  as  that  of  the  tetanus  bacillus, 
and  the  organism  is  also  anaerobic.  The  portal  of  entry  is 
usually  an  accidental  wound,  especially  where  there  is  crushing 
and  extensive  destruction  of  tissue. 

Effects. — 1.  Locally,  there  is  an  exudate  of  bloody  fluid  in 
the  tissues,  in  other  words  an  "cedema,"  accompanied  by  the 
formation  of  gas,  which  is  evident  by  a  peculiar  crepitation  of 
the  tissues  on  palpation.  The  process  spreads  rapidly  in  the 
part,  with  extreme  swelling  and  tissue  destruction.  2.  The 
constitutional  effects  are  severe  toxsemia,  prostration,  usually 
with  a  fatal  result.  The  prognosis  is  grave  even  Tvdth  early 
radical  treatment.  Principles  of  surgical  treatment  are  free, 
deep  incision  into  the  wound,  irrigation  and  constant  drainage, 
or  amputation  with  open  flaps,  if  possible. 

I.  Tubercle  BaciUi. — Distribution. — These  organisms  are 
derived  from  the  sputum  of  individuals  infected  with  pulmonary 
tuberculosis  or  the  discharge  of  active  lesions.  They  are  there- 
fore found  in  the  air,  dust,  and  on  various  articles,  especially 
in  the  homes  or  surroundings  of  those  suffering  with  the  disease. 

Portals  of  Entry. — Tubercle  bacilli  enter  the  body  most 
often  through  the  respiratory  tract,  and  it  is  stated  that  the 


36        ESSENTIALS  OF  SURGERY  FOR  NURSES 

initial  lesion  is  always  in  the  lung,  though  this  may  have  caused 
so  little  disturbance  that  it  is  entirely  overlooked  by  the  indi- 
vidual and  is  not  evident  in  the  history  as  taken  by  the  physi- 
cian. It  seems  possible  that  in  some  cases  the  portal  of  entry 
may  occur  in  other  regions — intestinal  tract,  tonsils,  and  rarely 
in  skin-wounds  when  exposed  to  virulent  tubercle  bacilli,  i.e., 
physicians,  butchers  and  veterinarians.  The  lesions  of  particular 
surgical  interest  are  usually  secondary,  though  at  the  time  such 
local  disease  may  represent  the  only  active  process  in  the  body. 
No  region  is  immune  to  the  organism. 

1.  Pulmonary  tuberculosis  is  of  surgical  interest  only  when 
complicated  by  pleurisy  or  empyema  except  as  a  contra  indica- 
tion to  general  anaesthesia. 

2.  Intestinal  and  peritoneal  tuberculosis  is  characterized  by 
ulcers  and  ''tubercles,"  which  may  cause  (a)  stricture  of  the 
intestine  and  obstruction;  (6)  large  inflammatory  masses;  or 
(c)  local  abscesses  with  peritonitis. 

3.  Urinary  tuberculosis  usually  begins  in  the  kidney,  and  is 
at  first  hmited  to  one  organ.  The  earliest  symptoms  are  referred 
to  the  bladder,  and  the  condition  is  often  wrongly  considered  as 
a  disease  of  that  structure. 

4.  Female  genital  tuberculosis  is  most  often  evident  as  a 
salpmgitis,  which  causes  an  obliteration  of  the  Fallopian  tube, 
and  may  represent  the  beginning  of  a  tubercular  peritonitis. 

5.  The  bones  and  articulations  are  often  involved,  apparently 
as  an  independent  process,  particularly  ui  children  and  young 
adults.  In  the  long  bones,  the  process  starts  in  the  "  epiphyses  " 
and  extends  to  the  joint  surface.  The  vertebra  are  also  involved 
and  are  comphcated  by  abscesses  which  often  extend  to  a  great 
distance  in  the  sheaths  of  attached  muscles,  "psoas  abscess." 

6.  Lymph-nodes  in  various  parts  of  the  body  are  infected 
from  a  portal  of  entry  in  the  dependent  region  drained  by  the 
affected  nodes,  though  the  original  lesion  may  not  be  evident. 
It  is  more  frequent  in  children  and  young  adults. 

Effects. — 1.  Local  destruction  of  tissue  with  the  formation 
of  characteristic  collections  of  cells  ("tubercles"),  and  suppura- 
tion, the  latter  often  being  due  to  secondary  infection  with  other 
organisms.  2.  Constitutional  effects  include  fatigue,  loss  of 
weight,  fever,  especially  in  the  evening,  night-sweats,  and 
prostration. 


SPECIFIC  PATHOGENIC  BACTERIA  37 

Principles  of  Treatment— 1.  Local,  rest  and  immobilization 
of  the  affected  part  to  improve  the  blood  supply.  In  some  cases 
excision  of  the  local  lesion  is  possible,  i.e.,  diseased  kidney,  or 
lymph-nodes.  Drainage  as  used  for  other  abscesses  is  particu- 
larly hable  to  result  in  persistent  sinus  formation  and  secondary 
infection,  and  is  therefore  avoided  if  possible.  2.  Constitutional 
treatment  is  the  most  important  and  must  be  applied  to  all  forms 
of  the  disease,  since  the  special  lesion  is  only  a  local  evidence  of 
a  general  tubercular  infection.  Therapy  includes  all  measures 
to  increase  the  general  resistance — rest,  improved  nutrition, 
over-feeding,  fresh  air,  sunshine,  medicines,  tonics,  iron,  iodine, 
or  cod-liver  oil.  3.  iS/^eayic  ^?-eaimen^  with  some  form  of  "  tuber- 
culin" is  sometimes  used  to  further  increase  the  resistance  of 
the  individual.  The  liability  to  recurrence  is  great,  and  may 
take  place  whenever  the  general  resistance  falls  below  normal. 
Treatment  must  extend  over  a  period  of  months  or  years. 

J.  The  vegetable  parasites  include  a  group  of  yeast-like 
organisms  which  cause  lesions  in  domestic  stock,  and  sometimes 
infect  individuals  peculiarly  exposed,  i.e.,  farmers,  and  those 
from  agricultural  districts.  1.  Actinomyces  causes  tj^pical 
reaction  in  skin  wounds  and  also  about  the  mouth,  jaws,  and 
respiratory  tract.  Typical  chronic  inflammatory  masses  occur 
which  resist  local  measures,  but  respond  to  proper  general 
treatment.  2.  Blastomyces,  a  similar  parasite,  causes  a 
peculiar  inflammatory  reaction  in  the  skin,  which  also  resists 
local  measures  but  responds  to  internal  treatment.  These 
organisms  can  usually  be  demonstrated  in  smears  from  the 
lesion,  and  the  treatment  is  general  rather  than  local. 

K.  Syphilis  is  caused  by  the  "spirochseta  pallida,"  which  is 
found  in  the  local  lesion  and  also  in  the  blood  and  tissue  fluids 
during  active  stages  of  the  disease.  There  are  two  forms  of 
the  disease,  (1)  congenital,  and  (2)  acquired. 

1.  In  CONGENITAL  SYPHILIS,  the  offspring  is  infected  in 
utero,  resulting  in  (a)  abortion;  (6)  premature  labor  with  a 
still-born  or  infected  baby  which  shows  evidence  of  an  active 
process;  (c)  a  poorly  nourished  infant  which  is  apparently 
normal  at  birth  but  shows  signs  of  the  disease  a  few  years  later. 

2.  The  ACQUIRED  FORM  is  caused  by  contact  with  discharge 
or  secretion  of  active  lesions,  either  by  venereal  exposure,  or 
innocently,  by  accidental  infection  of  wounds  or  abrasions  of 


38        ESSENTIALS  OF  SURGERY  FOR  NURSES 

the  skin  or  mucous  membrane.  The  disease  is  commonly 
considered  in  three  stages:  (a)  Primary,  or  stage  of  the  initial 
lesion.  The  portal  of  entry  consists  of  a  "hard  chancre,"  which 
is  a  peculiar  inflammatory  reaction  resembling  an  ulcer.  There 
is  considerable  induration  and  the  lesion  is  rather  characteristic. 
The  specific  organisms  can  be  isolated  in  the  local  tissues  or 
discharge.  (6)  Secondary  stage  of  general  infection  follows  in 
from  four  to  eight  weeks  and  is  characterized  by  constitutional 
reaction,  headache,  malaise,  some  fever  and  prostration.  The 
local  lesions  in  this  period  are:  (i)  Skin;  painless  eruptions 
which  imitate  almost  all  forms  of  skin  disease,  but  have  a 
peculiar  copper  color;  (ii)  mucous  membranes,  particularly  of 
the  mouth  and  throat,  show  painless  grey  ulcers  ("mucous 
patches"),  which  are  highly  infectious,  (c)  The  tertiary  stage 
represents  a  reawakening  of  the  disease  which  has  been  tempo- 
rarily dormant.  Lesions  consist  of  degeneration  of  the  tissues, 
peculiar  collections  of  connective-tissue  cells  forming  a 
"gumma,"  also  changes  and  degenerations  of  the  blood- 
vessels. 

Diagnosis  of  the  nature  of  questionable  lesions  is  made  from: 
(1)  The  history;  (2)  the  symptoms;  (3)  local  signs,  and  (4) 
certain  specific  tests,  Wassermann  from  the  blood  serum  and 
lutein,  skin  reaction. 

Surgical  Significance. — While  the  disease  is  essentially  a 
general  infection,  it  is  commonly  treated  in  the  surgical  depart- 
ment of  hospitals  and  has  special  interest  for  the  following 
reasons : 

1.  The  local  lesions  often  simulate  those  demanding  surgical 
measures,  but  fail  to  respond  till  specific  anti-syphilitic  treat- 
ment is  given. 

2.  Syphilis  may  be  present  in  an  individual  undergoing 
surgical  treatment  for  other  conditions,  and  cause  serious  com- 
phcations  unless  active  specific  therapy  is  given. 

3.  It  is  important  to  recognize  the  disease  in  order  to  prevent 
innocent  infections. 

4.  Certain  syphilitic  lesions  may  cause  symptoms  demanding 
local  surgical  treatment  in  addition  to  constitutional  measures. 

Treatment. — Locally,  consists  of  that  for  ulcers,  or  indicated 
by  the  nature  of  special  lesions.  General  treatment  is  internal, 
and  practically  limited  to  one  of  three  drugs: 


SPECIFIC  PATHOGENIC  BACTERIA  39 

1.  Mercury  in  some  form,  which  may  be  given  hypodermic- 
ally,  either  in  soluble  or  insoluble  preparations,  by  inunction, 
or  by  mouth. 

2.  Potassium  iodide,  or  sodium  iodide,  is  given  in  large  doses 
and  increased  as  rapidly  as  possible  to  the  limit  of  tolerance, 
especially  in  the  tertiary  forms  of  the  disease,  often  in  combina- 
tion with  other  drugs. 

3.  Arsenic,  usually  one  of  the  special  preparations — salvarsan 
or  neosalvarsan. 

DEMONSTRATIONS 

1.  Methods  of  preparing  and  staining  smears,  and  taking  cultures. 

2.  Collection  of  blood  for  "blood  culture." 

3.  Method  of  animal  inoculation. 

4.  A  case  of  persistent  sinus  with  cultures  demonstrating  mixed  infection. 

5.  A  case  of  erysipelas. 

6.  Demonstration  of  cultures  from  an  acute  suppurating  appendix. 

7.  Smears  from  specific  urethritis. 

8.  Study  of  case  history  of  gonorrhoeal  salpingitis,  with  demonstration  of 

specimen  removed  at  operation. 

9.  Study  of  case  history  of  tjrphoid  fever  showing  perforation  or  other 

surgical  complication. 

10.  Demonstration  of  use  of  tetanus  antitoxin  and  surgical  care  of  suspected 

wound. 

11.  Case  history  of  surgical  lesions  of  tuberculosis. 

12.  Cases  showing  congenital  lesions  of  syphilis. 

13.  Cases  showing  secondary  lesions  of  syphilis. 


CHAPTER  IV 

TUMORS  OR  NEW-GROWTHS 

Definition. — The  term  tumor  or  new-growth,  refers  to  certain 
pathological  masses  of  atypical  tissue  which  develop  in  various 
regions  of  the  body,  and  have  no  useful  function.  Inflarmnatory 
reactions  and  various  forms  of  compensatory  hypertrophy  of 
functioning  glands  or  muscle  ,are  excluded.  The  histologic  or 
microscopic  structure  is  somewhat  similar  to  some  one  of  the 
body  tissues,  but  is  always  atypical,  showing  more  or  less 
resemblance  to  rapidly  developing  embryonic  cells.  The  de- 
velopment does  not  follow  the  usual  form,  or  conform  to 
recognized  laws  of  normal  tissue  growth.  It  seems  that  for 
some  reason  the  growth  has  gone  wild,  loses  the  typical  rela- 
tions between  the  constituent  tissues,  and  the  entire  devel- 
opment is  apparently  without  purpose  or  order. 

Causes. — Three  factors  (1)  parasites;  (2)  abnormal  embry- 
onic development;  and  (3)  irritation  or  trauma,  represent  all 
which  are  seriously  defended  as  possibly  causing  new-growths, 
and  none  of  these  are  definitely  accepted  as  behig  the  positive 
cause  of  all  types  of  tmnors. 

1.  Paeasitic  micro-organisms  have  been  claimed  as  a 
possible  cause  of  nev^^-growths,  and  much  research  work  has 
been  done  to  establish  such  a  theory.  There  are  some  points 
of  similarity  between  certain  new-growths  and  infectious  proc- 
esses. However,  no  parasite  has  been  demonstrated  as  being 
the  constant  cause  of  any  particular  type  of  tumor.  Actual 
contagion  has  never  been  proven  clinically.  Observations  of 
such  apparent  cases  are  best  explained  as  actual  implantations 
of  tumor  cells,  or  as  coincidence.  Examples,  two  or  more  mem- 
bers of  a  family,  inhabitants  of  the  same  house,  or  nurse  and 
patient  may  develop  similar  type  of  tumor;  but  actual  contagion, 
as  the  term  is  understood  in  infections,  has  not  been  proved. 

2.  Abnormal  embryonic  development  explains  certain 
tumors.  Example,  "dermoids,"  hypernephroma,  and  some 
sarcomas  of  childhood.    It  is  explained  that  as  a  result  of  errors 

40 


TUMORS  OR  NEW-GROWTHS  41 

of  development,  bits  of  tissue  are  misplaced;  epithelium  is 
embedded  in  connective  tissue,  and  remains  dormant  for  a  long 
period  of  time.  It  is  stated  that  such  displaced  embryonic 
tissue  cells  may  under  certain  conditions  (repeated  irritations) 
later  develop  atypically  and  give  rise  to  a  tumor  or  new-growth. 

3.  Certain  types  of  irritation  are  claimed  to  stimulate  an 
atypical  tissue-cell  production  and  give  rise  to  new-growths. 
A  single  injury,  though  often  prominent  in  the  history,  is  usually 
unimportant  as  a  cause,  except  for  the  rare  possibility  of  atypical 
tissue  development  in  the  scar  formation  in  the  healing  of  a 
fracture,  lacerated  wound,  or  burn.  However,  it  is  regarded 
as  not  improbable  that  continued  irritation,  mechanical,  chemi- 
cal or  thermal,  of  epithelial  surfaces  may  lead  to  atypical 
development  of  cells,  and  become  an  important  causal  factor 
in  the  etiology  of  certain  new-growths.  Examples:  1.  Per- 
sistent and  repeated  irritation  as  a  cause  of  cancer  of  the  hp. 
2.  A  chronic  ulcer  of  the  pylorus,  being  exposed  to  the  mechan- 
ical and  chemical  irritation  of  the  gastric  contents,  is  claimed 
to  undergo  changes  in  the  structure  and  relations  of  the  epithehal 
cells,  resulting  in  cancer.  3.  Cancer  of  the  cervix  of  the  uterus 
is  often  preceded  by  lacerations  which  are  irritated  by  discharges. 
4.  Scars  of  burns  of  the  skin,  especially  those  caused  by  the 
Rontgen  ray.  5.  Certain  superficial  benign  tumors,  moles  and 
cysts,  which  are  exposed  to  irritation  or  repeated  trauma, 
undergo  malignant  degeneration.  It  can  be  stated  definitely 
that  irritation  or  repeated  traumata  are  at  least  important 
causal  factors  in  the  development  of  certain  types  of  new- 
growths.  However,  it  has  not  been  proven  that  these  factors 
are  the  sole  cause  of,  or  can  of  themselves  constantly  produce, 
any  type  of  tumor  formation.  None  the  less,  any  ulcer  or 
pathological  mass  which  persists  in  spite  of  reasonable  local 
measures,  or  which  is  exposed  to  irritation  and  trauma,  should 
be  considered  as  a  possible  developing  new-growth,  and  removed 
surgically  as  a  preventive  measure. 

Classification  of  tumors  is  based  on  one  of  three  grounds: 

A     /^r   •     1  /I-  Benign. 

^-  Cl^^^^l \2.  MaHlnant. 

[1.  Mural. 

B.  Shape  and  gross  relations    |  |X^^;,^i^^g^^ 

[4.  Polyps. 


42        ESSENTIALS  OF  SURGERY  FOR  NURSES 


Microscopical 
structure,  and 
tissue  from 
which  the 
growth  has 
developed 


1.  Epithehal. 


f Benign...   (Papilloma. 
J  1  Adenoma. 

[Mahgnant  (Squamous  cancer. 
lAdeno-carcinoma. 


Benign . 


2.  Connective  and 
supporting 
tissues,  blood 
and  lymph 
tissues 


Osteoma. 

Chondroma. 

Lipoma. 

Myoma. 

Fibroma. 

Neuroma. 

.Angioma. 


(Sarcoma.  Giant  cell. 
Small  round  ceU. 
Angio-sarcoma. 
Melano-sarcoma. 


A.  The  clinical  classification  of  benign  and  malignant  tumors 
is  most  important.  The  distinction  between  the  two  groups  is 
determined  ultimately  by  the  microscopic  relations  of  the  cells 
of  the  tumor  and  those  of  the  surrounding  tissues. 

1.  Benign  or  innocent  tumors  are  characterized  by  (a)  a 
definite  "capsule"  of  fibrous  tissue  which  surrounds  the  growth 
and  separates  it  from  the  tissues  in  which  it  develops;  (b)  the 
mass  remains  localized,  and  when  multiple,  each  tumor  is  an 
independent  local  growth  with  a  definite  capsule;  (c)  the  cells 
of  the  new-growth  never  break  through  the  capsule  or  invade 
the  surrounding  tissues;  (d)  cells  of  the  tumor  do  not  extend 
in  the  lymph  or  blood  stream,  and  ''metastases"  or  secondary- 
growths  do  not  occur  as  is  the  case  with  malignant  tumors; 
(e)  removal  is  simple  and  there  is  no  recurrence,  provided  the 
growth  with  its  capsule  is  completely  excised. 

The  effects  are  entirely  mechanical:  (1)  Pain  from  pressure 
on  nerve  endings  or  sensory  nerves;  (2)  hemorrhage,  from  pres- 
sure, or  erosion  of  blood-vessels;  (3)  obstruction  of  hollow  struc- 
tures, from  pressure  of  the  tumor — example,  blood-vessel, 
ureter  or  intestine;  (4)  gangrene  or  sepsis  may  develop  from 
interference  with  the  blood  supply  of  a  tumor;  (5)  degeneration 
and  changes  leading  to  the  development  of  a  malignant  new- 
growth  may  occur  under  certain  conditions,  not  well  understood. 
Constitutional  effects  are  not  specific  and  depend  largely  on 
disturbed  body  functions  due  to  the  mechanical  relations  of  the 
growth. 

Treatment  is  usually  complete  excision  of  the  tumor  with 


TUMORS  OR  NEW-GROWTHS  43 

its  capsule,  and  there  is  no  danger  of  recurrence.  The  indica- 
tions for  such  treatment  include  (1)  deformity  caused  by  the 
tumor;  (2)  effects  (pain,  hemorrhage,  or  disturbed  functions); 
(3)  changes  (gangrene  or  sepsis) ;  (4)  any  suspicion  of  malignancy. 
In  any  case  unless  this  can  be  positively  excluded  by  a  capable 
surgeon,  prompt  radical  removal  is  urgently  indicated. 

2.  Malignant  new-growths  show  important  character- 
istics: (a)  The  cells  of  the  new-growth  invade  the  surrounding 
tissues.  A  definite  capsule  is  absent  or  is  broken  through  by 
these  cells.  This  is  evident,  clinically,  (i)  by  the  fact  that  the 
mass  is  diffuse  and  irregular;  (ii)  that  tissue  layers,  fascia  or 
skin  are  adherent  to  the  mass;  (iii)  that  there  is  infiltration  about 
the  base  of  a  tumor,  or  (iv)  ulceration  of  the  epithelium  over 
the  surface. 

(6)  The  cells  of  the  new-growth  sooner  or  later  invade  the 
lymph-vessels  and  cause  enlargement  of  the  neighboring  lymph- 
nodes,  and  finally  give  rise  to: 

(c)  ''Metastatic"  or  secondary  growths  in  other  parts  of  the 
body.  Therefore  complete  excision  is  possible  only  while  the 
growth  is  limited  to  a  definitely  localized  area,  before  it  has 
extended  to  the  lymphatics,  or  metastases  have  occurred. 

(d)  Recurrence  is  likely  unless  the  growth  is  so  localized 
that  all  of  the  tumor  cells  can  be  removed.  This  is  possible 
only  in  the  early  stage  of  the  process,  therefore  prompt  radical 
excision  is  indicated  for  all  suspiciously  malignant  growths. 

Effects. — (a)  Local  results  from  pressure  occur  similar  to 
those  from  benign  growths.  Invasion  of  neighboring  tissues  or 
organs  is  not  uncommon,  resulting  in  hemorrhage  from  epithelial 
surfaces,  ulcerations,  fistula  formation,  and  constriction  or 
strictures  from  development  of  scar  tissue.  (6)  Constitutional 
effects  are  usually  secondary  to  disturbed  functions  as  the 
result  of  the  mechanical  relations  of  the  growth.  The  constitu- 
tional evidences  of  cancer,  when  present,  indicate  usually  an 
advanced,  or  inoperable  stage  of  the  disease.  In  fact,  these 
effects  are  often  due  to  the  presence  of  metastatic  tumors. 
There  may  be  severe  anaemia  from  hemorrhage,  malnutrition, 
cachexia,  and  finally  death  from  exhaustion.  It  has  never  been 
proven  that  there  are  specific  toxins  from  the  new-growth  which 
cause  constitutional  symptoms,  unless  gangrene  or  sepsis  is 
present. 


44        ESSENTIALS  OF  SURGERY  FOR  NURSES 

Principles  of  Treatment. — A  malignant  growth  is  operable, 
provided:  (a)  it  is  so  limited  that  complete  removal  "en  masse  " 
of  the  entire  tumor  formation  is  possible  without  injury  to  vital 
structures;  (6)  that  there  are  no  metastases  or  extensive  involve- 
ment of  the  lymphatics.  In  many  cases  a  growth  is  inoperable 
when  first  seen  by  the  surgeon.  This  is  evident  by  (a)  the 
presence  of  metastatic  masses  in  other  parts  of  the  body — 
examples,  masses  in  the  liver  in  case  of  cancer  of  the  intestinal 
tract;  (6)  extensive  involvement  of  the  tributary  lymph-nodes; 
(c)  extension  of  the  growth  into  important  structures  or  organs 
so  that  complete  removal  is  impossible.  The  indication  is  for 
radical  removal  of  the  involved  tissues,  together  with  the  lymph- 
vessels  and  nodes  of  the  area  at  the  earliest  possible  time. 
Various  local  therapeutic  measures  are  used  for  malignant 
growths  when  successful  removal  is  not  possible.  Some  of  these 
seem  to  retard  the  development,  remove  sloughs,  destroy  local 
sepsis,  and  also  tend  to  lessen  foul  discharge.  These  measures 
include  the  actual  cautery,  heat  with  the  electro-cautery, 
radium,  and  the  Rontgen  ray;  but  at  the  present  stage  of  our 
knowledge  these  are  reserved  for  inoperable  tumors  or  are  used 
in  connection  with  radical  removal. 

Cure. — A  patient  is  considered  as  cured,  following  radical 
operation  for  malignant  disease,  only  after  five  years  have 
elapsed  with  no  evidence  of  local  recurrence  or  development  of 
metastatic  growths.  However,  it  is  known  that  these  may 
occur  even  after  this  period  in  rare  cases. 

From  a  practical  standpoint  we  should  bear  in  mind  the 
following  considerations:  Any  new-groT\i;h  is  always  abnormal 
and  a  potential  source  of  danger.  The  evidences  of  malignancy 
as  usually  described  are  caused  by  extension  of  the  growth  into 
surrounding  structures  and  tissues.  That  when  these  signs  can 
be  demonstrated  by  the  surgeon,  the  growth  is  no  longer  a 
localized  mass  which  can  be  easily  removed.  Tumor  cells  may 
already  have  invaded  the  neighboring  lymph  channels  or  lymph- 
nodes,  or  have  been  carried  to  remote  parts  of  the  body,  causing 
metastases.  Therefore,  a  growth  which  shows  only  what  we 
consider  as  the  "early"  signs  of  malignancy  has  already  passed 
beyond  the  first  stage  and  is  now  extending  as  an  actively 
malignant  process.  After  these  signs  are  evident  the  chance 
for  successful  complete  removal,  with  freedom  from  recurrence, 


TUMORS  OR  NEW-GROWTHS  45 

and  cure  is  less  than  one-half  as  good  as  before  any  of  these  are 
demonstrated.  Furthermore,  certain  types  of  growth — pedun- 
culated tumors  with  irregular  blood-supply,  or  those  exposed  to 
irritation — are  prone  to  undergo  an  atypical  cell  development 
or  "malignant  degeneration,"  after  which  extension  and  metas- 
tases occur  rapidly.    The  lessons  are  obvious. 

Any  new-growth,  including  skin  tumors,  should  be  examined 
at  once  by  a  competent  surgeon.  Unless  he  can  definitely  and 
absolutely  exclude  malignancy  or  the  probability  of  malignant 
degeneration,  his  advice  will  be  exploration  or  radical  removal, 
which  should  be  accepted  without  question.  Any  tumor  which 
is  causing  pain,  undergoing  change  in  size,  shape  or  consistency, 
should  be  removed  at  once.  There  are  no  "early"  signs  of 
cancer  which  are  specific.  Any  new-growth  is  much  safer 
preserved  in  alcohol  in  a  bottle  than  in  the  patient's  tissues. 

B.  On  the  basis  of  shape  of  the  growth  and  its  gross  relations 
to  surrounding  structures,  certain  terms  are  used.  Most  tumors 
tend  to  be  round  except  where  this  is  modified  by  unyielding 
structures,  as  bone.  Mural  tumors  are  located  in  the  wall  of  a 
sofid  organ — example,  uterus.  Sub-serous  growths  develop 
immediately  under  a  serous  membrane,  and  may  be  either 
sessile,  i.e.,  with  a  broad  base  of  attachment,  or  pedunculated, 
i.e.,  with  a  narrow  pedicle  which  contains  the  nutrient  vessels 
to  the  tumor.  Sub-mucous  growths  bear  the  same  relation  to  a 
mucous  surface  and,  when  pedunculated,  are  often  spoken  of  as 
"polyps,"  in  which  case  they  project  freely  into  the  cavity. 
Pedunculated  tumors  are  liable  to  certain  complications  due  to 
torsion  of  the  pedicle  and  interference  with  the  blood  supply. 
There  immediately  results  swelling  of  the  tumor  with  severe 
pain,  and,  later,  gangrene  with  sepsis. 

C.  The  pathological  classification  is  based  on  the  micro- 
scopical structure  of  the  gro\vth  and  the  tissue  from  which  it 
originates.  From  this  standpoint  there  are  two  main  groups  of 
tissues:  1.  The  epithelial  tissues  (squamous  protective),  secre- 
tory (glandular).  2.  The  supporting  tissues  and  vascular  struc- 
tures, capillaries,  and  lymphatics. 

Epithelial  Benign  Tto^ors. — (a)  Squamous  epithelium, 
i.e.,  that  of  the  skin,  mouth,  nose,  vagina,  and  bladder,  gives 
rise  to  certain  "warts,"  "corns,"  papillomas,  and  polyps.  (6) 
Secreting  epithelium,  breasts,  glands,  intestinal  tract,  or  uterus. 


46        ESSENTIALS  OF  SURGERY  FOR  NURSES 


develops  benign  "adenomas,"  atypical  masses  resembling  the 
structure  of  glandular  epithelium.  They  usually  contain  a 
considerable  proportion  of  connective  or  fibrous  tissue,  forming 
the  "adenofibroma"  or  "adenomyoma." 

Epithelial  Malignant  Tumors  (Fig.  7). — Epithelioma, 
carcinoma,  or  cancer,  (a)  Squamous  epithelium  gives  rise  to 
the  epithelioma,  a  slow-growing  tumor  which  rarely  forms  metas- 


NU/7/fl 


Fig.  6. — Section  of  uterus,  showing  types  of  benign  new-growths  (fibroids). 

tases  but  resists  all  local  treatment  except  removal.  The 
squamous  mucous  membranes  give  rise  to  certain  malignant 
polyps  which  are  much  more  dangerous  than  the  skin  growths. 
(6)  Secreting  or  glandular  epithelium  tends  to  develop  the 
adenocarcinoma,  which  is  rapid  in  growth  and  highly  malignant. 
This  form  of  tumor  may  originate  in  any  structure  which  con- 
tains secreting  epithelium — sweat-glands,  breast,  intestinal 
tract,  uterus,  or  thyroid  gland. 

The  SUPPORTING  and  vascular  tissues  include  bone,  car- 
tilage, teeth,  connective  tissue,  muscle,  blood-forming  struc- 


TUMORS  OR  NEW-GROWTHS 


47 


tures,  lymph-nodes  and  capillaries.  The  neT\'-gro"uiihs  may  be 
composed  entirely  of  a  single  tissue,  but  more  often  are  mixed, 
for  example,  include  bone  and  cartilage,  osteochondroma. 

Benign  connective-tissue  tumors  may  be  briefly 
mentioned: 

(a)  Osteoma,  a  true  ossification,  when  pure  is  excessively 
hard  and  slow  in  gro^^th.  It  often  contains  cartilage  or  connec- 
tive tissue. 


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Fig.  7. — Alalignant  epithelial  tumor.    Cancer. 

(6)  Chondroma.  This  growth  usually  develops  from  hyaline 
cartilage  and  often  contains  bone. 

(c)  Lipoma  is  composed  of  fat  similar  to  that  of  the  subcu- 
taneous structures.  Though  it  rarely  has  a  true  capsule,  the 
lipoma  is  fairly  distinct  from  surrounding  structures,  and  is 
never  malignant. 

id)  Myoma. — These  tumors  usually  develop  from  the  non- 
striated  muscle,  particularly  the  uterus,  and  are  often  mixed 
with  connective  or  fibrous  tissue,  forming  the  "  fibromyoma"  or 
"fibroid."  See  Fig.  6,  page  46.  The  myoma  from  striated 
or  voluntary  muscle,  the  rhabdomyoma,  is  very  rare. 


48        ESSENTIALS  OP  SURGERY  FOR  NURSES 

(e)  Connective  tissue  tumors,  or  true  fibroids,  are  rare  except 
combined  with  other  forms  where  fibrous  tissue  is  present  in 
normal  or  excessive  amounts.  Pure  fibroids  are  occasionally 
found  in  connection  with  certain  tendons. 

(/)  Neuroma  and  glioma  are  tumors  peculiar  to  nervous 
tissues  but  are  really  derived  from  the  supporting  structures. 

(g)  Vascular  and  lymph  structures  give  rise  to  (1)  congenital 
angioma  or  nsevus,  also  hemangioma,  composed  of  capillaries, 
and  contain  blood.  (2)  Lymphangioma,  certain  moles  which 
may  be  congenital  or  acquired. 

Malignant  connective-tissue  tumors,  sarcomas,  are 
composed  of  connective-tissue  cells  of  varying  size,  on  the  basis 
of  which  we  classify  them  into  (a)  ''giant-cell  sarcoma,"  which 
is  slow-growing  and  only  relatively  malignant;  (6)  ''mixed-cell 
sarcoma";  (c)  "small  round-cell  sarcoma,"  which  is  of  rapid 
growth  and  highly  malignant.  Of  the  above  mentioned  groups, 
metastases  are  not  common,  but  local  growth  may  be  very 
rapid,  and  recurrence  is  common  and  rapid;  (d)  "angiosar- 
coma," which  develops  from  the  lymph  structures  and  is  very 
malignant;  (e)  "melanosarcoma,"  so  called  from  the  presence 
of  the  pigment  "melanin"  in  the  tumor  cells.  This  type  of 
tumor  originates  either  in  the  choroid  coat  of  the  eye  or  in 
certain  pigmented  "moles"  of  the  skin,  and  is  extremely  malig- 
nant. Metastatic  growths  occur  so  early  and  extensively  that 
successful  removal  is  rare. 

DEMONSTRATIONS 

1.  Epithelioma  from  X-ray  burn  or  other  type. 

2.  Specimens  showing  different  forms  of  tumors:  mural,  sessile,  and  pedun- 

culated. 

3.  History  and  X-ray  plates  showing  metastases   of  a  malignant  new- 

grow^th  in  bone, 

4.  Case  history  of  malignant  new-growth  from  pigmented  mole. 

5.  Specimens  and  history  showing  types  of  cancer. 

6.  Same  for  types  of  sarcoma. 

7.  Statistics  showing  comparative  results  of  early  and  late  radical  operation. 


CHAPTER  V 

WOUNDS,    HEMORRHAGE,   SURGICAL   OPERATIONS 
AND  ANAESTHESIA 

A  wound  is  a  break  in  the  continuity  of  tissues,  usually 
communicating  with  the  skin  or  one  of  the  epithelial  surfaces. 

A.  Closed  wounds  of  the  deep  structures  without  communi- 
cation to  the  surface  are  usually  the  result  of  serious  injury — 
fractures,  traumatic  rupture  of  the  internal  organs.  Example, 
liver  or  spleen  (from  crushing  injury  or  blows  with  large  blunt 
objects,  as  planks) — and  are  followed  by  evidences  of  internal 
hemorrhage  or  shock. 

B.  Open  wounds  are  those  which  communicate  with  the 
surface,  and  are  the  more  frequent.  There  are  two  types, 
(1)  clean,  aseptic,  and  (2)  infected  or  septic  wounds. 

1.  Clean,  aseptic  wounds  are  practically  limited  to  elective 
surgical  incisions,  made  under  aseptic  precautions,  and  pro- 
tected from  all  contamination  by  septic  material.  Clean  aseptic 
wounds  may  become  infected  by:  (a)  A  break  in  the  aseptic 
technic  at  the  operation  or  subsequent  dressing.  (6)  Develop- 
ment of  organisms  in  the  deep  layers  of  the  skin,  which  have 
survived  the  surgical  preparation.  These  may  cause  cellulitis, 
or  extend  along  penetrating  sutures  to  deep  layers,  forming  the 
"stitch-abscess."  (c)  Contamination  at  the  operation  of  a 
clean  wound  by  the  contents  of  a  septic  cavity — abscess,  intes- 
tinal tract,  bladder,  vagina,  or  skin,  {d)  The  presence  in  a 
wound  of  necrotic  or  devitalized  tissue  cells,  collection  of  blood 
serum,  defective  drainage,  or  tissues  constricted  by  a  tight 
ligature. 

2.  Presumably  infected  or  septic,  "dirty  wounds,"  include 
most  accidental  wounds  and  those  where  there  is  not  absolute 
prevention  of  contamination  by  pathogenic  germs.  Infection 
may  result  from  (a)  the  object  causing  the  injury;  (6)  dirt  or 
foreign  material  carried  into  the  wound;  (c)  from  the  skin  or 
secretions  of  the  body,  and  (d)  penetration  of  the  intestinal 
tract,  bladder  or  vagina.  Predisposing  factors  are :  Low  general 

4  49 


50        ESSENTIALS  OF  SURGERY  FOR  NURSES 

resistance  as  in  other  infections,  and,  locally,  necrotic  or  devital- 
ized tissue  in  the  wound,  and  poor  drainage. 

Classification  of  Accidental  Wounds. — 1.  Incised 
wounds  have  clean-cut,  even  edges,  caused  by  sharp  instru- 
ments, with  no  crushing  or  bruising  of  tissues;  result  in  healthy, 
well-nourished  wound  edges  and,  in  the  absence  of  infection, 
heal  promptly. 

2.  Lacerated  or  contused  wounds  are  those  with  ragged, 
irregular  edges,  often  with  flaps  which  have  a  narrow  pedicle 
and  insufficient  blood  supply.  The  surrounding  parts  are 
often  crushed  and  injured,  and  there  may  be  pockets  and 
cavities;  result  in  poor  drainage  and  with  great  liability  to 
infection. 

3.  Punctured  wounds  have  a  small  opening  and  a  long  narrow 
channel  or  pocket,  often  extending  deeply  into  the  tissues.  They 
include  stab  wounds,  gunshot  and  bayonet  wounds,  or  those 
produced  by  nails  and  splinters.  Foreign  material  may  be 
carried  in  and  pathogenic  organisms,  especially  anaerobes 
(tetanus),  develop  remotely  from  the  surface  and  oxygen. 
Drainage  is  poor  and  infection  frequent. 

Repair  of  Wounds. — A.  Clean  surgical  wounds  heal  "per 
primam, "  or  by  "first  intent,"  provided  infection  does  not 
occur.  There  is  no  tissue  destruction  or  suppuration  and  a 
minimum  of  scar  tissue  results.  Course  of  healing:  (1)  There 
is  an  exudate  or  pouring  out  of  Ijrmph  and  leucocytes  into  the 
wound,  tending  to  fill  the  cavity.  This  solidifies  and  forms  a 
gelatinous  cement  substance  holding  the  edges  together.  (2) 
Capillaries  grow  into  this  mass  and  connective- tissue  cells 
develop,  forming  granulation  tissue,  and  finally  a  dense  scar  or 
cicatrix.  (3)  The  special  tissue  cells  (epithelial  or  muscular) 
tend  to  grow  over  or  into  the  scar,  which  is  finally  covered  or 
replaced  to  a  greater  or  less  extent.  This  process  may  be  incom- 
plete, especially  in  case  of  extensive  scars. 

B.  Infected  or  dirty  wounds:  In  these  there  is  more  tissue 
destruction,  suppuration  is  usually  present,  and  the  process  is 
much  slower.  Causes :  (1)  Anything  which  prevents  the  accurate 
coaptation  of  healthy  wound  edges.  (2)  The  presence  of  necrotic 
or  devitalized  tissue.  (3)  Suppuration.  (4)  Defective  drain- 
age. As  a  result  of  this  there  is  formed  more  granulation 
tissue,  which  is  easily  infected.    This  tissue  may  become  exces- 


WOUNDS  51 

sive  or  "exuberant"  and  project  above  the  surface,  preventing 
the  final  healing  by  overgrowth  of  epithelium. 

Treatment. — A.  Clean-wounds,  measures  are  largely  prophy- 
lactic: (1)  Absolute  asepsis;  (2)  accurate  coaptation  of  healthy 
edges  with  no  cavity  or  "dead  space";  (3)  absolute  hsemostasis; 
and  (4)  aseptic  precautions  in  the  after-care.  Should  infection 
occur  the  treatment  is  that  for  infected  wounds. 

B.  Accidental,  presumably  infected,  wounds  present  three 
indications:  (1)  To  repair  injury;  (2)  to  control  hemorrhage; and 
(3)  to  prevent  infection. 

1.  Measures  to  repair  injury  will  depend  on  the  nature  of 
the  wound  and  the  tissues  involved.  Absolute  asepsis  is  the 
first  requisite  and  any  extensive  procedure  will  have  to  be 
delayed  till  the  patient  can  be  brought  to  suitable  surroundings, 
which  should  be  done  as  promptly  as  possible.  Preparation  of 
the  accidental  wound  for  surgical  dressing  must  be  done  T\dth 
extreme  care  to  avoid  unnecessary  contamination.  It  should 
be  covered  with  sterile  gauze  held  with  a  sterile  forceps  while 
the  surrounding  skin  surface  is  cleansed  with  benzine  or  some 
similar  agent,  avoiding  large  amounts  of  water  or  antiseptic 
which  could  carry  dirt  into  the  wound.  Sterile  towels  are  now 
arranged  about  the  field  as  for  an  aseptic  operation,  and  the 
necessary  procedures  are  carried  out  with  perfect  aseptic 
technic.  <.  At  this  time  the  wound  is  cleansed  of  foreign  material, 
necrotic  tissue  removed,  hemorrhage  controlled,  and  severed 
structures  sutured.  In  deep  accidental  wounds  drainage  is 
often  necessary  and  moist  antiseptic  dressings  may  be  applied. 

In  early  suitable  cases,  closure  as  a  clean  wound  is  possible 
and  is  preferable  since  it  prevents  extensive  suppuration.  In 
less  favorable  cases  this  cannot  be  done  and  special  dressings  or 
apparatus  are  used.  The  objects  are,  to  destroy  pathogenic 
micro-organisms,  render  the  wound  sterile  or  practically  so, 
and  to  produce  healthy  wound  edges  which  may  be  closed. 
A  somewhat  complicated  method  described  as  the  "Carrel- 
Dakin  technic"  is  used  rather  extensively.  This  involves  the 
use  of  a  preparation  of  hypochlorite  of  lime,  which  must  be 
prepared  in  a  special  manner  to  avoid  irritation  of  the  tissues. 
After  proper  surgical  treatment  of  the  wound,  perforated  drain- 
age tubes  are  so  placed  that  all  surfaces  will  be  bathed  by  the 
golution  which  is  carried  through  the  tubes  from  an  irrigator, 


52        ESSENTIALS  OF  SURGERY  FOR  NURSES 

The  solution  deteriorates  rapidly  and  must  be  replaced  every 
two  hours.  Smears  are  taken  from  the  wound  surfaces  at  regular 
intervals  and  are  studied  under  the  microscope.  When  bacteria 
can  no  longer  be  demonstrated  the  wound  can  be  closed  as  a 
clean  surgical  procedure.  The  technic  is  difficult  and  must  be 
followed  to  the  most  minute  detail.  On  this  account  the  method 
can  be  used  only  under  somewhat  ideal  surroundings. 

2.  Control  of  hemorrhage  is  the  most  urgent  indication  for 
first  aid  and  should  be  accomplished  with  no  unnecessary 
meddling  with  the  wound.  Arterial  hemorrhage  is  the  most 
serious  and  requires  active  measures.  First  aid,  "tourniquet": 
This  is  properly  an  elastic  bandage,  though  any  material  may 
be  used  in  emergency.  The  bandage  is  applied  above  the  wound 
and  made  tight  enough  to  control  the  bleeding.  In  most  cases 
this  is  sufficient  till  the  patient  can  be  brought  to  suitable 
surroundings  for  surgical  care.  Dangers:  A  tourniquet  which 
is  applied  too  tightly  or  left  on  too  long  will  cause  pain  and 
may  do  serious  harm  to  underlying  structures.  Therefore  the 
bandage  should  be  only  tight  enough  to  safely  control  bleeding, 
and  is  to  be  removed  as  soon  as  aseptic  surgical  care  can  be 
given.  If  sterile  dressings  are  at  hand,  moderate  hemorrhage 
can  be  controlled  by  packing  the  wound  and  applying  a  tight 
pressure  bandage  extending  above  and  below  the  wound. 
Direct  surgical  control  of  hemorrhage  assumes  aseptic  technic. 
Arterial  bleeding  requires  ligation  (tying)  of  the  artery,  always 
the  central  end  and  often,  also,  the  peripheral  end.  In  case  of 
moderate  venous  or  capillary  hemorrhage  tight  suture  of  the 
divided  tissues  is  often  sufficient. 

3.  Prevention  of  infection:  This  involves  perfect  asepsis 
in  the  first  aid  and  in  the  subsequent  care  of  the  wound.  Ordi- 
nary aseptic  principles  are  easily  overlooked  in  an  emergency, 
especially  when  there  is  serious  bleeding.  The  prevention  of 
sepsis  is  therefore  prophylactic,  (a)  At  the  first  aid  avoid 
handling  the  wound,  use  sterile  dressings  and  mild  antiseptic 
compresses  or  dressings,  (b)  Surgical  dressing,  copious  irriga- 
tions, removal  of  foreign  material  and  necrotic  tissue,  evacuation 
of  pockets  and  dead  space,  and  ample  provision  for  drainage, 
(c)  The  prophylactic  injection  of  antitoxin  or  serum:  example, 
tetanus  antitoxin,  in  suspicious  wounds,  (d)  Subsequent  care 
of  the  wound;  asepsis  a^nd  the  use  of  mild  antiseptic  solution-s, 


HEMORRHAGE  53 

removal  of  necrotic  tissue,  and  maintaining  adequate  drainage 
till  healing  is  complete. 

In  the  care  of  minor  accidental  wounds,  free  hemorrhage 
should  be  encouraged,  tincture  of  iodine,  or  similar  antiseptic, 
appHed  into  the  wound  (but  with  no  irrigation  or  antiseptic 
solution),  and  a  pressure  bandage  applied  to  control  bleeding, 
if  necessary. 

Note:  Solutions  of  mercury  preparations,  especially  the 
bichloride,  "corrosive  subhmate,"  must  never  be  used  where 
iodine  has  been  applied,  since  there  is  formed  a  chemical  com- 
pound which  is  irritating  to  the  skin.  Strong  solutions  of  car- 
bolic acid  and  its  derivatives,  lysol  and  similar  commercial 
preparations  have  serious  local  effect  on  exposed  surfaces. 
They  act  as  local  ansesthetics  and  extensive  burns  may  occur 
painlessly  with  no  warning  to  the  patient.  A  few  cases  of 
gangrene  of  finger  or  toes  have  developed  when  strong  solutions 
were  used  as  wet  dressings. 

Bites  of  dogs  and  domestic  animals  are  usually  infected  and 
require  prompt  care — free  exposure,  cauterization,  or  strong 
antiseptics  locally — and  are  allowed  to  heal  as  an  open  wound. 
If  the  animal  actually  has  "rabies"  or  there  is  reason  to  suspect 
this  disease,  it  should  be  killed  at  once  and  the  head  packed  in 
ice  and  sent  to  the  nearest  public  health  laboratory  for  examina- 
tion. Unless  this  disease  can  be  reasonably  excluded,  the  patient 
should  be  sent  to  the  nearest  Pasteur  Institute  for  prophylactic 
treatment  before  symptoms  are  evident.  The  treatment  is 
specific  and  prevents  the  disease  if  used  early  in  the  incubation 
period,  but  is  much  less  eSicacious  after  symptoms  have 
appeared. 

Hemorrhage  may  be  either  (A)  open,  or  (B)  concealed. 

A.  Open  hemorrhage  occurs  in  accidental  wounds  or  in 
regions  where  the  blood  appears  at  the  surface.  In  many  cases 
of  this  type  the  source  is  inaccessible  to  surgical  measures. 
Examples — stomach,  lungs,  intestine  or  uterus.  The  amount 
of  blood  which  is  lost  is  difiicult  to  determine  but  is  usually 
overestimated,  since  bleeding  is  always  startling.  Arterial 
hemorrhage  may  be  rapidly  fatal  if  not  promptly  controlled. 
However,  moderate  loss  of  blood  is  quickly  compensated  by  the 
absorption  of  fluids  from  the  tissues.  The  blood-forming  organs 
overcome  the  resulting  anaemia  in  a  comparatively  short  time. 


54        ESSENTIALS  OF  SURGERY  FOR  NURSES 

Repeated  losses  of  blood,  even  though  of  moderate  amounts 
(from  uterine  bleeding  or  hemorrhoids),  cause  serious  anaemia 
which  is  not  easily  overcome.  Bleeding  may  be  (1)  arterial; 
(2)  venous;  (3)  capillary. 

1.  Arterial  hemorrhage  is  characterized  by  a  steady  or 
pulsile  flow,  evidently  under  pressure,  and  is  controlled  only  by 
clamping  or  ligating  the  artery  or  compression  of  the  vessel 
higher  in  its  course. 

2.  Venous  hemorrhage  is  continuous,  under  less  pressure 
than  is  the  arterial  form,  and  is  more  easily  controlled  by  packing 
the  wound.  Injury  to  a  large  vein  may  cause  rapidly  fatal 
bleeding. 

3.  Capillary  bleeding  occurs  in  wounds,  is  rarely  serious, 
being  easily  controlled  by  local  pressure,  packing  the  wound,  or 
by  sutures.  Occasionally  such  bleeding  may  be  persistent  when 
occurring  from  highly  vascular  or  inflamed  surfaces.  Example, 
mucosa  of  the  nose  and  throat. 

Treatment. — 1.  Control  of  bleeding:  (a)  Local  measures 
have  been  considered  in  the  care  of  accidental  wounds.  (6) 
Constitutional  therapy  to  alter  the  composition  of  the  blood 
and  favor  coagulation  is  necessary  in  certain  cases,  including 
transfusion  of  blood,  injection  of  whole  blood,  blood-serum,  or 
horse-serum,  and  calcium  compounds  by  mouth. 

2.  Measures  to  overcome  the  loss  of  blood  are  usually 
applied  after  the  bleeding  has  been  controlled.  Fluids  are  sup- 
plied to  raise  the  blood-pressure  and  overcome  the  cerebral 
anaemia.  Transfusion  of  blood  is  indicated  in  more  serious  cases, 
intravenous  infusion  of  normal  saline,  hypodermoclysis,  or 
proctoclysis  in  less  urgent  conditions.  Stimulants  and  tonics 
are  used  later  to  increase  the  production  of  blood-cells  and 
hsemoglobin. 

B.  Concealed  hemorrhage  may  occur:  1.  Into  the  tissues 
of  the  body  and  is  usually  self-limited  by  pressure  and  coagula- 
tion of  the  blood.  It  is  more  often  the  result  of  injury  to  a  blood- 
vessel by  fracture  or  dislocation,  less  often  the  spontaneous 
rupture  of  a  diseased  artery,  "aneurism."  There  is  pain  due 
to  distention  of  the  tissues  by  the  extravasated  blood.  If  this 
reaches  the  surface  there  is  "ecchymosis"  or  the  "black  and 
blue"  mark  due  to  the  presence  of  blood-cells  and  pigment 
haemoglobin  in  or  under  the  skin.    A  haematoma,  blood  tumor, 


HEMORRHAGE  55 

is  formed  by  the  coagulation  of  the  blood,  and  may  be  absorbed 
if  not  too  extensive.  In  other  cases  the  clot  is  liquefied,  forming 
a  fluid  "hsematocele."  There  is  always  danger  of  a  hsematoma 
or  hsematocele  becoming  infected,  since  it  is  composed  of  dead 
tissue  and  has  low  resistance  to  any  bacteria  which  may  reach 
it.  Evacuation  or  aspiration  under  aseptic  precautions  is 
indicated  in  some  cases. 

2.  Hemorrhage  may  take  place  into  one  of  the  hollow  organs 
or  one  of  the  body  cavities  (pericardium,  peritoneum).  From 
some  of  the  organs  (stomach,  intestine,  or  uterus)  the  blood 
eventually  reaches  the  surface,  but  serious  or  fatal  hemorrhage 
may  previously  have  occurred,  and  the  condition  practically 
amounts  to  concealed  hemorrhage.  Causes  of  this  type  of 
bleeding  are  varied  and  include  many  medical  or  surgical  lesions. 
Examples:  Post-partum  hemorrhage,  extension  of  an  ulcer  of 
the  stomach  or  intestine  into  a  blood-vessel,  pulmonary  hemor- 
rhage in  tuberculosis,  traumatic  rupture  of  the  Kver  or  spleen, 
rupture  of  an  ectopic  pregnancy,  spontaneous  rupture  of  an 
aneurism.  Conditions  in  the  new-born  causing  delay  in  the 
coagulation  time  of  the  blood  result  in  persistent  bleeding  from 
the  mucous  membranes.  Family  tendency  in  individuals  who 
are  spoken  of  as  "bleeders,"  also  in  cases  of  persistent  jaundice, 
where  small  wounds  bleed  persistently  in  spite  of  ordinary 
attempts  to  control. 

Effects. — The  special  mechanical  local  effects  of  blood  clots 
Mall  be  mentioned  in  connection  with  certain  regions  (brain). 
When  hemorrhage  occurs  into  a  free  cavity  and  there  is  httle 
or  no  pressure  on  the  bleeding  vessel  and  no  tendency  to  spon- 
taneous control  of  bleeding  by  coagulation  as  in  the  case  of  more 
sohd  tissues.  Hemorrhage  is  likely  to  continue  till  the  blood- 
pressure  falls,  when  coagulation  of  blood  may  occlude  the  bleed- 
ing vessel.  If  the  general  blood-pressure  is  raised  by  stimulants 
before  a  reasonably  solid  clot  has  formed,  the  bleeding  is  likely 
to  recur.  General  effects  are  similar  to  those  associated  with 
external  hemorrhage,  but  the  early  symptoms  are  important  in 
the  recognition  of  the  condition.  There  is  (a)  pallor;  (h)  rapid, 
irregular  pulse  (120  to  150)  which  becomes  faint  and  irregular; 
(c)  temperature,  if  previously  elevated,  falls  to  subnormal. 
There  is  a  peculiar  faintness,  restlessness,  shortness  of  breath, 
and  finally  unconsciousness  from  cerebral  anaemia,  and  death. 


56        ESSENTIALS  OF  SURGERY  FOR  NURSES 

The  immediate  effects  of  a  single  non-fatal  hemorrhage  are 
rapidly  offset,  but  this  is  not  true  of  repeated  bleedings  over  a 
short  period  of  time. 

Treatment. — Local  special  surgical  measures  for  the  control 
of  bleeding  are  indicated  in  certain  conditions  where  there 
is  reasonable  hope  of  reaching  the  source.  Examples,  ectopic 
pregnancy,  puerperal  hemorrhage,  or  rupture  of  the  liver  or 
spleen. 

General  measures  meet  two  indications:  (a)  to  prevent 
recurrence,  (h)  to  overcome  the  effects. 

(a)  To  prevent  recurrence :  Absolute  rest  in  bed,  with  the 
ice-bag  locally.  Morphine  to  prevent  vomiting,  peristalsis  or 
cough,  and  also  nervousness  and  restlessness.  Therapy,  to  alter 
the  composition  of  the  blood  and  shorten  the  coagulation  time, 
includes  transfusion  of  blood,  injection  of  whole  blood,  blood- 
serum,  horse-serum  or  lime  salts. 

(6)  Measures  to  overcome  the  effects  of  bleeding  are  usually 
reserved  till  this  is  controlled,  since  rise  of  blood-pressure  may 
cause  recurrence.  These  include  transfusion,  pituitrin,  adrenalin 
with  saline  by  hypodermoclysis  or  intravenously,  stimulants  and 
tonics. 

Surgical  Operations,  Preparations,  Aftercare,  Complications, 
and  Ansesthesia. — The  term  surgical  operation  as  commonly 
used  refers  to  any  procedure  which  involves  the  cutting  or 
suture  of  various  structures.  It  really  is  a  broader  term  than 
is  usually  understood,  and  includes  many  manipulations  where 
there  is  no  cutting.  Examples:  Reduction  of  fractures  and 
dislocations,  certain  obstetrical  procedures,  forceps  and  version, 
procedures  which  require  anaesthesia,  may  cause  shock,  or  be 
complicated  by  sepsis. 

Minor  operations  are  those  which  produce  little  or  no 
danger  to  life,  or  to  serious  complications.  Major  or  capital 
OPERATIONS  expose  the  patient  to  more  or  less  risk  of  fatal 
outcome.  The  terms  are  somewhat  relative,  depending  to  a 
considerable  degree  upon  the  physical  condition  of  the  individual 
at  the  time  of  the  operation. 

A.  Indications. — Emergency  operations  are  those  done  for 
grave  conditions  where  relief  must  be  more  or  less  immediate 
to  prevent  serious  damage,  or  to  save  hfe.  The  urgency  of  the 
condition  may  be  a  matter  of  minutes,  hours,  or  days.     Ex- 


SURGICAL  OPERATIONS  57 

amples:  Obstruction  of  the  trachea,  demanding  instant  trache- 
otomy, ruptured  gastric  ulcer  or  gangrenous  appendix  with 
rapidly  spreading  peritonitis,  strangulated  hernia  or  intestinal 
obstruction,  malignant  new-growth. 

Elective  operations  are  those  where  the  exact  time  is  a  matter 
of  some  choice  and  there  is  no  serious  danger  of  fatal  or  grave 
results  by  moderate  delay.  Examples:  Removal  of  benign 
tumor,  repair  of  hernia  or  obstetrical  lacerations,  correction  of 
deformities,  or  certain  plastic  operations. 

B.  Contraindications  to  operations  include  anything 
which  renders  the  danger  from  the  particular  operation  or  its 
complications  greater  than  that  of  the  original  condition. 
There  may  be:  1.  Contraindication  to  general  anaesthesia  (see 
p.  68).  2.  Serious  shock  in  traumatic  or  emergency  cases  may 
require  special  treatment  before  the  necessary  operation  can  be 
done.  3.  Certain  constitutional  conditions  (diabetes,  arterio- 
sclerosis, some  forms  of  kidney  disease,  advanced  age,  extreme 
malnutrition  or  cachexia,  syphilis,  tuberculosis  or  acute  infec- 
tions) are  likely  to  interfere  with  wound  healing  or  to  predispose 
to  serious  complications. 

C.  Preparation  of  the  patient  for  operation  includes 
many  details  which  are  left  to  the  nurse  in  charge: 

1.  Operations  at  home  may  be  unavoidable  on  account  of 
extreme  emergency,  distance  from  the  hospital,  or  condition  of 
the  patient.  With  ingenuity  and  attention  to  each  detail,  it  is 
possible  to  provide  for  major  operations  in  any  modern  home. 
In  such  cases  the  nurse  in  charge  will  usually  have  to  arrange 
the  details.  The  room  should  be  as  near  the  patient's  bedroom 
as  possible,  and  in  many  instances  this  room  is  used.  The 
chief  considerations  are  good  light,  ample  room,  and  access 
to  running  water  or  a  bathroom.  Extra  furniture  is  removed, 
the  floors  and  walls  wiped  down  with  cloths  moistened  with 
antiseptic  solution.  In  the  absence  of  a  regular  operating  table, 
a  kitchen  or  dining  table  can  be  adapted.  Extra  stands,  chairs, 
basins,  and  irrigators  are  provided.  An  ample  supply  of  dress- 
ings, gauze,  cotton,  and  apparatus  are  prepared,  or  obtained, 
freshly  sterihzed,  from  the  hospital. 

2.  The  transportation  of  a  sick  patient  to  the  hospital  will 
usually  be  directed  by  the  physician,  but  the  nurse  must  attend 
to  the  details.    Sudden  jarring  or  movement  must  be  avoided 


58        ESSENTIALS  OF  SURGERY  FOR  NURSES 

in  many  cases,  because  of  pain,  danger  of  rupture  of  a  gangrenous 
appendix,  spread  of  peritonitis,  or  internal  hemorrhage.  Frac- 
tures, dislocations,  or  severe  injuries  must  be  immobihzed  in  a 
temporary  dressing.  The  patient  is  best  made  comfortable  on 
a  cot  or  stretcher  which  can  be  placed  in  the  ambulance.  Plenty 
of  hot-water  bottles,  heaters,  or  blankets  must  be  provided  to 
prevent  chilling.  Morphine  may  be  ordered  in  certain  cases  to 
relieve  pain.  If  possible  the  nurse  is  to  accompany  the  patient 
to  attend  to  emergencies  in  the  ambulance. 

3.  Preparation  of  the  patient:  Various  routine  methods  pre- 
vail in  different  hospitals,  and  only  general  principles  can  be 
discussed,  (a)  Mental  preparation:  It  is  of  the  utmost  im- 
portance that  the  patient  approach  the  operation  in  a  calm, 
hopeful  state  of  mind.  To  this  end,  all  preparations  are  to  be 
made  without  unnecessary  discomfort  or  excitement.  The 
entire  atmosphere  is  that  of  calm  assurance  and  quiet  confidence. 
Discussion  of  the  patient's  condition  is  to  be  avoided,  also  the 
account  of  similar  cases.  Sleep,  especially  the  night  preceding 
the  operation,  is  most  essential,  and  a  hypnotic,  such  as  veronal 
or  chloral,  may  be  ordered  for  this  purpose.  The  use  of  mor- 
phine hypodermically  in  the  morning  is  a  matter  for  individual 
judgment  of  the  surgeon.  In  certain  cases  where  it  is  necessary 
to  avoid  the  deleterious  effects  of  apprehension  and  fear  (exoph- 
thalmic goitre)  a  special  procedure  is  developed.  The  patient  is 
kept  in  the  hospital  for  treatment,  which  includes  suitable 
sedatives,  some  of  which  are  given  hypodermically.  She  is  not 
informed  as  to  the  exact  date  of  operation,  but  is  prepared  by 
daily  short  inhalations  of  nitrous  oxide.  Finally  she  is  given 
the  preliminary  morphine,  fully  anaesthetized  and  transported 
to  the  operating  room,  in  this  manner  eliminating  the  psychic 
element  of  fear.  (6)  Cleansing:  A  complete  bath,  either  tub 
or  sponge,  is  customary  preceding  the  preparation  of  the  opera- 
tive field.  For  the  latter,  special  technics  are  in  use  in  different 
hospitals.  Except  in  emergency  cases,  the  preliminary  prepara- 
tion consists  of  either  a  scrub  with  gauze  and  green  soap  and 
shaving,  after  which  the  field  is  covered  with  aseptic  or  in  some 
cases  v/ith  a  mildly  antiseptic  dressing,  or  the  preliminary 
cleansing  is  done  with  an  iodine-benzine  mixture  followed  by  a 
dry  shave  and  aseptic  dressing.  Final  preparation  on  the  table 
may  include  simply  painting  with  3  per  cent,  or  5  per  cent. 


SURGICAL  OPERATIONS  59 

tincture  of  iodine,  or  the  use  of  special  solutions,  such  as 
McDonald's  solution: 

Pyxol 1 

Acetone 40 

Alcohol 60 

or  similar  mixture : 

Liquor  Cresolis  Comp 2 

Acetone 35 

Alcohol,  q.s.ad 100 

(c)  Diet  and  care  of  the  bowels :  The  stomach  and  intestinal 
tract  should  be  as  nearly  empty  as  possible,  but  not  irritated 
by  violent  catharsis.  At  the  same  time  the  patient  must  not 
be  starved,  and  surgeons  are  aware  that  injudicious  restriction 
of  food  preceding  operation  may  cause  serious  post-operative 
complications.  For  the  day  preceding  operation,  unless  there 
be  a  special  contraindication  (peritonitis, etc.), the  patient  should 
receive  a  light,  easily  digestible  diet,  which  will  leave  little 
residue.  Unless  there  are  special  contraindications  there  is  little 
objection  to  a  hot  drink,  tea,  black  coffee,  or  malted  milk,  early 
in  the  morning,  several  hours  preceding  an  anaesthetic.  Contra- 
indications: Threatened  peritonitis,  intestinal  obstruction,  or 
the  probability  of  operation  on  the  gastro-intestinal  tract. 
Gastric  lavage  may  be  indicated  preceding  the  anaesthetic  or 
operation  in  case  of  excessive  vomiting,  with  intestinal  obstruc- 
tion, or  in  emergency  cases  with  a  full  stomach.  The  bowels, 
if  previously  well  open,  may  require  only  a  soapsuds  enema. 
If  possible,  nothing  should  be  given  which  will  interfere  with  a 
good  night's  rest  preceding  the  operation.  An  active  cathartic 
is  best  given  at  least  36  hours  previously,  and  the  bowels  moved 
by  enema  the  night  or  morning  immediately  preceding  the 
operation.  Active  or  repeated  catharsis  leaves  the  tract  in  an 
irritated  condition  and  is  likely  to  cause  post-operative  dis- 
tention, "gas  pains, 'Tor  even  obstruction.  Cathartics  are  contra- 
indicated  in  cases  which  suggest  peritonitis,  acute  appendicitis, 
or  intestinal  obstruction,  unless  especially  ordered,  and  the 
bowels  must  be  moved  by  enemas. 

{d)  Preparation  for  anaesthesia :  The  question  of  a  prelimi- 
nary hypodermic  of  morphine  (gr.  |  to  gr.  1.4)  with  or  without 
atropine  (gr.  tW)}  is  to  be  decided  by  the  surgeon,  preferably 


60        ESSENTIALS  OF  SURGERY  FOR  NURSES 

for  each  patient.  If  properly  used,  this  will  do  much  to  insure 
an  easy  anaesthetic.  It  should  be  given  at  least  one-half  hour 
before  the  patient  goes  to  the  operating  room,  and  after  all 
other  preparations  are  complete  so  that  there  is  no  further  dis- 
turbance. There  must  be  ample  protection  from  cold;  a  warm 
shirt  or  pad  for  the  chest,,  the  limbs  well  covered,  and  plenty 
of  blankets  or  hot-water  bottles.  For  all  pelvic,  abdominal,  or 
vaginal  operations,  the  patient  must  be  catheterized  or  allowed 
to  void  urine  immediately  before  the  hypodermic  is  given,  to 
be  sure  that  the  bladder  is  empty.  The  mouth  should  be 
cleansed  with  an  alkaline  antiseptic  wash,  and  false  teeth  re- 
moved. The  nurse  usually  accompanies  the  patient  to  the 
operating  room  and  is  expected  to  be  familiar  with  the  essential 
points  on  the  chart,  pulse,  temperature,  and  general  condition 
of  the  patient.  She  will  usually  remain  mitil  anaesthesia  is 
complete,  and  in  some  instances  throughout  the  operation. 
She  should  be  informed  of  the  nature  and  extent  of  the 
operation  in  order  to  understand  the  particular  after-care, 
but  in  no  instance  to  discuss  with  the  patient  or  friends. 
The  unvarying  rule  is  that  all  inquiries  are  to  be  referred 
to  the  surgeon. 

The  care  of  the  patient  on  the  table  is  usually  in  charge  of 
the  operating  room  staff.  It  is  important  to  avoid  chilling ;  see 
that  the  chest  and  unexposed  parts  are  well  covered,  and  that 
artificial  heat  is  used  if  necessary.  The  position  must  be  as 
comfortable  as  possible,  the  arms  supported  preferably  at  the 
side,  avoiding  tight  constrictions  or  an  arm  hanging  over  the 
side  of  the  table.  A  pad  or  pillow  under  the  back  will  often 
prevent  relaxation  under  anaesthesia  and  severe  post-operative 
backache.  Proper  lithotomy  position  with  no  constriction 
about  the  limbs  will  avoid  severe  pain  and  possibly  a  compres- 
sion neuritis.  With  care  and  attention,  the  change  to  and  from 
the  "Trendelenberg  position"  may  be  made  simply,  with  no 
delay  or  confusion.  Assistance  to  the  anaesthetist  may  be 
expected  of  the  private  nurse,  including  observation  of  the 
pulse,  blood-pressure,  or  respiration;  keeping  the  chart,  giving 
hypodermics,  hypodermoclysis,  or  proctoclysis. 

D.  After-care  and  Post-operative  Complications. — 
The  dressings,  drainage  tubes,  or  bandages  are  attended  to  by 
the  assistants  or  operating  room  nurse,  but  the  private  nurse  is 


SURGICAL  OPERATIONS  61 

usually  responsible  for  returning  the  patient  to  the  bedroom. 
She  must  see  that  the  patient  is  properly  placed  on  the  carriage, 
that  arms  and  limbs  are  well  protected,  that  there  are  sufficient 
blankets,  and  that  there  is  no  exposure.  Constant  attention 
is  necessary  to  prevent  the  aspiration  of  vomitus  or  mucus. 
Above  all,  there  must  be  no  delay.  The  bed  is  previously 
arranged,  with  the  necessary  pads,  drawsheets,  and  hot-water 
bottles,  protected  to  prevent  burns.  The  unconscious  patient 
is  carefully  moved  and  placed  in  bed. 

1.  Dangers. — (a)  Injury  to  an  arm,  dislocation  or  paralysis, 
by  allowing  it  to  lie  under  an  unconscious  patient.  (6)  Burns 
from  unprotected  hot-water  bottles  or  electric  pads,  (c)  Aspira- 
tions of  vomitus  or  mucus.  The  nurse  must  be  in  constant 
attendance  till  the  patient  is  conscious  and  in  good  condition. 

2.  Special  Positions. — (a)  "Fowler's,"  imitates  the  sitting 
posture  and  aims  to  secure  the  collection  of  fluid  or  pus  in  the 
pelvis  by  means  of  gravity — to  secure  better  drainage;  to  localize 
the  infection  and  prevent  general  peritonitis;  and  to  keep  septic 
material  from  the  upper  peritoneum  where  absorption  is  more 
rapid.  (6)  Position  for  shock,  with  the  feet  elevated,  (c) 
Bradford  frame  and  special  extension  apparatus  for  fractures. 

3.  Drainage  may  be  provided  by  means  of:  (a)  Copious 
gauze  dressings  to  be  changed  frequently,  (6)  Gall-bladder, 
by  special  tube  pinned  to  the  dressings,  (c)  Bladder,  by  a 
tube  sutured  to  the  wound,  and  frequent  irrigations,  or  a 
retention  catheter. 

4.  Normal  After-care. — Unless  otherwise  ordered,  the  patient 
is  usually  kept  on  her  back,  with  the  head  low,  for  the  first  12 
to  24  hours,  after  which  there  is  little  objection  to  careful 
turning  from  side  to  side,  and  a  pillow.  A  back-rest  is  used 
inside  of  a  week,  or  earlier,  in  the  aged.  The  time  in  bed  varies 
according  to  the  nature  of  the  operation  and  the  condition  of 
the  patient.  The  usual  rule  of  about  ten  days  represents  a  safe 
minimum.  It  is  important  to  avoid  physical  or  mental  over- 
exertion and  fatigue,  which  may  easily  be  brought  about  by 
too  early  rising  or  too  many  visitors,  and  result  in  discouraging 
set-backs.  The  late  convalescence  is  equally  important,  and 
the  patient  must  make  haste  slowly  after  leaving  the  hospital. 
Fven  in  the  case  of  patients  who  have  been  previously  well, 
an  elective  major  operation  imposes  a  considerable  burden.    At 


62        ESSENTIALS  OF  SURGERY  FOR  NURSES 

the  least  from  two  to  four  months  should  elapse  before  such  a 
patient  is  to  be  considered  as  absolutely  well. 

5.  Relief  of  Pain.  — A  certain  amount  of  discomfort  is  unavoid- 
able, and  when  this  is  Hkely  to  be  excessive  the  surgeon  commonly 
orders  a  hypodermic  of  morphine  given  as  soon  as  consciousness 
is  regained.  For  the  well-being  of  the  patient,  even  minor  dis- 
comforts must  be  promptly  relieved,  for,  if  allowed  to  accumu- 
late, the  condition  of  the  patient  may  become  alarming.  Per- 
sistent or  excessive  pain  may  be  due  to:  (a)  Distention  of  the 
wound  caused  by  the  formation  of  a  hsematoma,  or  the  devel- 
opment of  local  infection,  and  calls  for  examination  by  the 
surgeon.  (6)  Intestinal  distention  and  lack  of  peristalsis,  "gas 
pains,"  which  are  usually  relieved  by  a  high  enema,  either  simple 
soapsuds  or  with  turpentine.  Unless  specially  contraindicated 
these  may  be  given  Tvdthin  the  first  12  to  24  hours  and  repeated 
as  necessary.  Persistent  pain  and  distention  suggest  intestinal 
obstruction,  or,  with  fever,  indicate  peritonitis. 

6.  Fluids  and  Feeding. — In  certain  conditions  such  as  severe 
hemorrhage,  shock,  or  prolonged  operation,  fluid  may  be  rapidly 
supplied  by  means  of  intravenous  infusion,  hypodermoclysis,  or 
proctoclysis,  (a)  Intravenous  infusion  is  reserved  for  the  more 
extreme  emergencies  and  is  done  by  the  surgeon.  Normal  saline 
at  about  body  temperature  is  used,  and  sterile  instruments  and 
solutions  should  be  readily  accessible  at  all  times,  (h)  Hypo- 
dermoclysis, the  slow  injection  of  fluid,  usually  normal  saline 
at  body  temperature,  into  the  loose,  subcutaneous  tissue  of  the 
breast  or  abdomen  (but  not  the  back),  is  incUcated  in  less  urgent 
conditions,  (c)  Proctoclysis,  slow  injection  of  fluid  by  the 
rectum,  supplies  the  body  \nX\i  water,  prevents  thirst,  and 
avoids  the  necessity  of  giving  fluids  by  mouth  when  this  is 
contraindicated.  It  is  used  as  a  routine  by  some  surgeons,  and 
when  especially  indicated  by  others.  The  fluid  must  be  main- 
tained at  body  temperature,  given  in  a  proper  apparatus  to 
insure  slow,  regular  administration  and  prevent  discomfort  or 
expulsion  of  the  fluid.  Solutions  used  may  be  tap-water,  normal 
saline,  glucose  or  sugar  solution,  or  special  formulas.  A  single 
high  enema,  consisting  of  hot  coffee  or  normal  saline,  to  be 
retained,  is  often  ordered  in  case  of  shock. 

Nutrient  enemas,  while  of  doubtful  value  for  prolonged  use, 
^rg  often  ordered  for  a  lew  days  when  feeding  by  the  mouth  i§ 


SURGICAL  OPERATIONS  63 

impossible  or  contraindicated.  Various  formulas  are  given  in 
texts  on  nursing  methods.  The  mixture  must  not  be  irritating 
to  the  bowel.  The  volume  must  not  be  too  large  to  be  retained 
(four  to  six  ounces),  the  rectum  cleansed  by  saline  irrigation, 
and  the  enema  not  repeated  within  from  four  to  six  hours. 

7.  Care  of  the  Wound. — All  dressings  are  usually  done  by  the 
surgeon  unless  especially  directed.  Clean  wounds  are  rarely 
dressed  more  than  twice  during  the  first  ten  days.  Infected 
wounds  will  require  more  frequent  change  of  dressings,  some  of 
which  may  be  left  to  the  nurse.  For  all  dressings  there  is  needed 
antiseptic  solution,  bichloride  1  to  1000,  lysol  |-  per  cent,  or 
sat.  boric,  sterile  towels  and  dressings,  bandage  scissors,  adhe- 
sive, fresh  bandage  and  binder,  sterile  instruments,  the  patient 
in  a  comfortable  position  so  that  there  may  be  no  delay. 

Post-operative  complications  include:  (1)  shock,  (2) 
hemorrhage,  (3)  pain,  (4)  excessive  vomiting,  (5)  retention  of 
urine,  (6)  fever,  infection  or  sepsis,  (7)  thrombosis,  (8) 
pneumonia. 

1.  Shock  is  characterized  by  a  sudden  depression  of  certain 
vital  centres  which  control  the  heart-beat  and  blood-pressure, 
and  complicates  serious  painful  injuries,  burns  and  surgical 
operations,  not  infrequently  being  fatal. 

Causes  include  several  factors  acting  alone  or  in  combination : 
(a)  Painful  sensory  stimuli  reaching  the  central  nervous  system, 
even  under  anaesthesia,  from  crushing  injuries,  burns,  or  con- 
tinued operative  manipulation  of  sensitive  tissues.  (6)  Psychical 
stimuli  (fright,  apprehension,  or  fear)  are  said  to  have  a  similar 
depressing  effect,  (c)  Hemorrhage,  or  sudden  loss  of  blood, 
possibly  by  causing  a  fall  in  general  blood-pressure,  (d)  Tox- 
aemia from  the  anaesthetic — chloroform,  or  ether,  and  to  a  less 
degree,  nitrous  oxide. 

Effects  and  Symptoms. — There  is  a  depression  of  the  central 
nervous  system,  possibly  due  to  cerebral  anaemia,  with  vaso- 
motor disturbance,  evident  first  by  a  fall  in  the  blood-pressure. 
The  onset  is  often  sudden,  with  "syncope"  or  fainting,  or  may 
be  preceded  by  restlessness  and  mental  apprehension.  During 
this  time  the  pulse  becomes  rapid,  thready,  low  tension  and 
irregular.  The  blood-pressure  falls,  the  heart  becomes  weak 
and  death  is  imminent.  Shock  in  traumatic  conditions  may 
present  the  most  urgent  indication  for  treatment,  to  a  degree 


64        ESSENTIALS  OF  SURGERY  FOR  NURSES 

that  operative  measures  are  postponed  till  this  is  overcome. 
The  prognosis  is  difficult  to  determine,  but  depends  on  the 
prompt  recognition  of  the  condition  and  proper  treatment. 

Principles  of  Treatment. — (a)  Prophylactic:  Avoid  painful 
manipulation  of  injuries  and  burns,  and  reheve  pain  with  mor- 
phine. During  operation,  maintain  regular,  adequate  anaes- 
thesia, possibly  reinforced  with  local  anaesthesia.  Manipulation 
of  sensitive  tissue  is  to  be  avoided  as  much  as  possible.  Prompt 
recognition  is  essential  and  nothing  done  which  will  increase  the 
irritability  of  the  nervous  system.  On  this  basis,  strychnine 
or  similar  stimulants  are  contraindicated.  Quiet  and  rest  is 
essential  and  is  often  best  obtained  with  morphine.  (6)  Meas- 
ures to  restore  the  vasomotor  balance  are  indicated.  Diffusible 
stimulants,  camphorated  oil,  caffeine,  brandy  or  ether,  may  be 
ordered  hypodermically.  Normal  saline,  possibly  with  a  few 
drops  of  1  to  1000  adrenalin  is  used,  intravenously,  by  hypo- 
dermoclysis  or  proctoclysis,  depending  on  the  urgency  of  the 
condition.  Caffeine,  in  the  form  of  hot  coffee,  given  by  the 
rectum  is  of  great  value. 

2.  Post-operative  Hemorrhage. — (a)  Open  bleeding  from  the 
wound  is  evident  in  the  dressing  and  calls  for  prompt  attention 
by  the  surgeon.  Moderate  bleeding  into  a  closed  wound  causes 
pain  from  the  distention  of  the  tissues  and  leads  to  the  formation 
of  a  hsematoma,  with  danger  of  local  infection,  (b)  Concealed 
hemorrhage  has  been  considered  (see  page  54).  It  is  most  likely 
to  occur  soon  after  the  operation,  but  in  some  instances  develops 
several  days  later  due  to  local  infection  and  sloughing.  The 
condition  is  often  confused  with  shock.  The  effects  are  restless- 
ness, faintness,  local  distress,  shortness  of  breath,  rapid,  weak, 
and  irregular  pulse.  Such  suggestive  changes  demand  the 
prompt  attention  of  the  surgeon.  In  the  meantime,  absolute 
quiet,  the  ice-bag  locally,  and  possibly  morphine  hypodermically 
is  indicated. 

3.  Excessive  Pain. — (a)  In  the  wound  (i)  soon  after  the 
operation,  is  caused  by  hemorrhage  and  distention  of  the  tissues. 
It  calls  for  prompt  examination  by  the  surgeon,  who  may  find 
it  necessary  to  remove  one  or  more  sutures  and  evacuate  the 
contents.  Wet  dressings  of  mild  antiseptics  are  often  used, 
(ii)  Local  pain  several  days  later  is  usually  due  to  wound  infec- 
tion and  is  accompanied  by  fever.    It  demands  an  examination 


SURGICAL  OPERATIONS  65 

by  the  surgeon,  and  is  evident  by  local  redness,  swelling,  tender- 
ness, and  possibly  fluctuation.  Early  attention  is  necessary  to 
secure  evacuation  of  septic  material,  to  prevent  extension  and 
breaking  down  of  the  entire  wound.  It  is  then  treated  as  an 
infected  wound. 

(6)  General  abdominal  pains,  "gas  pains,"  due  to  intestinal 
distention,  are  frequent  following  operations  where  the  peri- 
toneum has  been  invaded,  especially  if  there  has  been  peritonitis. 
Persistent  abdominal  pain  is  also  an  early  indication  of  develop- 
ing peritonitis  or  intestinal  obstruction,  and  requires  careful 
attention.  It  is  best  relieved  by  high  enemas  of  soapsuds  with 
turpentine.  Unless  there  is  special  contraindication  (operations 
on  the  rectum  or  lower  bowel),  an  enema  may  be  given  within 
the  first  24  hours  or  as  soon  as  pain  is  distressing,  and  repeated 
until  flatus  is  passed  freely.  An  ice-bag  to  the  abdomen  is  of 
great  value.  Morphine  is  contraindicated  unless  specially 
ordered.  Pituitrin  hypodermically  in  smafl  doses  is  used 
considerably. 

4,  Nausea  and  vomiting  are  common  after  general  anaes- 
thesia, particularly  ether,  during  the  first  24  hours,  and  may  be 
prolonged  by  injudicious  feeding.  If  proctoclysis  is  used,  fluids 
by  mouth  can  easily  be  withheld  till  nausea  and  vomiting  cease. 
Fluids  by  mouth  must  be  started  carefully  with  sips  of  water  or 
bits  of  ice  and  gradually  increased  with  the  addition  of  albumen 
water,  milk  diluted,  or  butter-milk,  avoiding  incompatible  mix- 
tures. Persistent  nausea  or  vomiting  calls  for  gastric  lavage, 
which  usually  controls  the  situation. 

Other  causes  for  severe  vomiting  are  (a)  acute  dilatation 
of  the  stomach,  (6)  intestinal  obstruction,  and  (c)  developing 
peritonitis. 

(a)  Acute  dilatation  of  the  stomach  is  caused  by  spastic 
contraction  of  the  orifices,  pylorus  and  oesophageal  opening, 
with  atonic  dilation  of  the  wall.  The  organ  may  reach  tre- 
mendous size,  cause  evident  distention  of  the  abdomen,  and 
embarrass  respiration  or  the  heart-beat.  There  is  persistent 
nausea  and  attempts  to  vomit,  which  are  usually  unproductive 
but  interfere  with  rest.  If  neglected,  the  condition  may  become 
fatal.  Treatment:  Prompt  evacuation  of  the  contents  with 
stomach-tube,  lavage  with  sodium  bicarbonate  solution,  and  in 
some  cases  a  cathartic  (castor-oil)  is  left  in  the  stomach.  The 
5 


66        ESSENTIALS  OF  SURGERY  FOR  NURSES 

use  of  the  tube  may  have  to  be  repeated  as  the  condition 
recurs. 

(b)  Intestinal  obstruction  is  characterized  by  persistent 
vomiting,  which  eventually  becomes  fecal,  abdominal  pain,  and 
distention. 

(c)  Peritonitis  also  causes  continued  nausea  and  vomiting, 
abdominal  pain,  elevation  of  temperature,  and  rapid  pulse. 

5.  Retention  of  urine  is  not  infrequent  following  operations 
and  often  necessitates  the  use  of  the  catheter,  which,  however, 
is  to  be  avoided  if  possible.  Causes:  Lack  of  the  secretion  of 
urine  is  due  to  (a)  pathological  changes  in  the  kidneys,  effects 
of  the  anaesthetic  or  operation,  or  lack  of  fluids  in  the 
body;  (6)  injury  to  the  bladder  or  urethra,  extreme  dis- 
tention of  the  bladder;  (c)  inability  to  use  a  bed-pan  or 
urinal,  nervousness. 

Every  effort  is  to  be  made  to  secure  voluntary  passage  of 
urine  before  there  is  discomfort  from  over-distention  of  the 
bladder.  Many  patients  are  self-conscious,  nervous,  and  not 
able  to  use  a  urinal  or  bed-pan  readily.  Much  tact  and  judg- 
ment may  be  needed.  A  local  douche  or  enema  is  valuable, 
and,  when  not  contraindicated,  it  may  be  preferable  to  allow  a 
semi-sitting  posture.  Frequently  a  single  catheterization  is  all 
that  is  necessary,  but  too  often  it  has  to  be  repeated  several 
times.  Objections:  The  danger  of  infecting  the  bladder  and 
causing  ''cystitis"  is  great  when  catheterization  is  repeated,  no 
matter  how  carefully  aseptic  technic  is  followed.  In  using  the 
catheter,  it  is  necessary  to  have  good  light  and  free  exposure  in 
order  that  there  may  be  no  contamination  of  the  sterile  catheter 
by  contact  with  the  bedding  or  external  parts. 

6.  Fever  following  operation  for  excision  or  drainage  of  a 
local  inflammatory  lesion  indicates  extension  of  the  process, 
incomplete  evacuation  of  the  septic  material,  blocking  of  the 
drainage,  remote  pockets,  or  development  of  independent  lesions 
in  other  parts  of  the  body,  and  calls  for  the  attention  of  the 
surgeon.  Following  clean  operations  there  should  be  no  ele- 
vation of  temperature.  Rarely  there  is  a  temporary  rise  to 
from  99°  to  100°  which  can  be  said  to  be  without  significance. 
Any  fever  which  persists  for  24  hours  must  be  explained,  and 
the  surgeon  has  to  exclude  infection  in  the  wound,  peritonitis, 
thrombosis,  or  some  independent  septic  process. 


SURGICAL  ANAESTHESIA  67 

7.  Thrombosis  is  an  occasional  complication  following 
from  5  to  15  days  after  abdominal  and  pelvic  operations, 
especially  when  there  is  sepsis,  less  often  after  clean  cases,  or 
operations  on  remote  parts  of  the  body.  It  most  frequently 
involves  the  saphenous  or  femoral  vein,  especially  the  left. 
It  is  associated  with  fever  to  103°,  pain  in  the  groin,  with 
painful  swelling  of  the  foot  and  leg.  The  duration  is  from 
one  to  two  weeks.  Complications  are  embolus,  permanent 
partial  occlusion  of  the  vessel  with  varicose  veins  and  recurrent 
swelling. 

Treatment. — Rest  in  bed  and  immobilization  of  the  limb  as 
long  as  there  is  fever,  tenderness  or  swelling,  no  massage  to  the 
limb,  cotton  flannel  bandage  with  a  soothing  lotion  or  ointment 
(belladonna  and  mercury),  and  later  a  pressure  bandage.  A 
cradle  is  necessary  to  protect  the  limb  from  the  pressure  of  the 
bedding. 

8.  Bronchopneumonia  occurs  as  a  serious  post-operative  con- 
dition in  certain  types  of  patients,  especially  the  aged  or  those 
who  are  handicapped  by  severe  malnutrition  or  cachexia. 
Causes:  Aspiration  of  mucus  or  septic  material  from  the  mouth, 
prolonged  immobilization  in  bed,  which  is  favorable  to  hypo- 
static congestion  of  the  lungs.  Prophylaxis  consists  of  (a)  care 
of  the  mouth,  attention  to  prevent  the  aspiration  of  vomitus 
or  mucus  while  the  patient  is  unconscious;  (6)  protection  from 
exposure  and  chilling;  and  (c)  aged  patients,  and  those  who  are 
cachectic  must  not  be  kept  on  their  back  longer  than  necessary. 
The  early  use  of  the  back-rest,  turning  from  side  to  side,  and 
measures  to  stimulate  deep  breathing,  are  indicated  as  early  as 
possible. 

Surgical  anaesthesia  includes  various  methods  used  to  prevent 
pain  caused  by  manipulating  or  cutting  sensitive  tissues.  It  may 
be  (A)  general,  or  (B)  local. 

A.  General  anesthesia  is  induced  by  the  inhalation  of 
certain  drugs,  (1)  chloroform,  (2)  ether,  or  (3)  nitrous  oxide, 
and  produces  unconsciousness  to  painful  stimuh,  with  relaxation 
of  the  voluntary  muscles.  Indications:  Dressings,  manipula- 
tions, or  operations  which  cause  severe  pain ;  dressing  extensive 
burns  or  severe  injuries;  reduction  of  fractures  or  dislocations; 
extraction  of  teeth;  minor  and  major  surgical  operations.  Con- 
traindications vary  for  special  drugs  (see  later),  but   include 


68        ESSENTIALS  OF  SURGERY  FOR  NURSES 

advanced  age,  certain  heart  lesions,  pulmonary  tuberculosis, 
marked  kidney  or  arterial  changes,  cachexia,  or  severe  malnu- 
trition. Such  conditions  must  be  considered  by  the  surgeon, 
who  will  decide  the  question  of  local  or  general  ansesthesia. 

1.  Chloroform  induces  prompt  and  complete  ansesthesia  and 
causes  few  post-operative  effects.  It  is  rarely  used  on  account 
of  the  following  objections: 

(a)  The  margin  of  safety  between  surgical  ansesthesia  and 
dangerous  or  fatal  narcosis  is  exceedingly  narrow.  (6)  Sudden 
death  on  the  operating  table  from  certain  reflex  causes  or 
profound  narcosis  has  occurred  and  is  apparently  unavoidable, 
(c)  Pathological  changes  in  the  liver  and  kidneys  have  been 
demonstrated  after  repeated  or  prolonged  chloroform  anses- 
thesia. (d)  Late  after-effects,  vomiting  and  acidosis,  may  be 
fatal. 

Chloroform  should  be  administered  only  by  one  who  thor- 
oughly appreciates  the  dangers,  and  on  an  open  mask  with 
plenty  of  air,  avoiding  irregular  administration. 

Ether  is  the  most  generally  used  except  in  certain  clinics 
where  nitrous  oxide  is  favored.  It  induces  complete  ansesthesia 
and  muscular  relaxation,  with  a  wide  margin  of  safety.  The 
administration  is  simple,  and  there  are  few  serious  after-effects. 
Nausea  and  vomiting  depend  to  a  great  extent  upon  the  condi- 
tion of  the  gastro-intestinal  tract.  The  stomach  should  be 
empty,  the  stomach-tube  being  used  in  certain  cases.  Ether  is 
said  to  be  contraindicated  in  some  forms  of  intestinal  obstruc- 
tion, also  bronchitis,  severe  asthma  or  pulmonary  tuberculosis, 
advanced  age  or  extreme  cachexia. 

3.  Nitrous-oxide  gas  is  kept  in  iron  tanks  under  pressure  and 
given  with  a  special  apparatus,  usually  in  combination  with 
oxygen.  Extensive  experience  is  required,  and  the  gas  should 
be  administered  only  by  an  expert.  It  induces  prompt  and 
complete  ansesthesia,  causes  less  shock,  and  is  followed  by  no 
special  after-effects.  It  is  considered  by  many  to  be  the  anses- 
thetic  of  choice,  especially  in  doubtful  cases. 

B.  Local  and  regional  anesthesia  include  (1)  infil- 
tration ansesthesia,  (2)  regional  ansesthesia,  and  (3)  spinal 
ansesthesia. 

It  is  induced  by  the  subcutaneous  injection  of  ansesthetic 
drugs.    Cocaine  in  |  per  cent,  to  ^  per  cent,  solution,  which  is 


SURGICAL  ANAESTHESIA  69 

objected  to  on  account  of  not  infrequent  toxic  effects,  and 
because  solutions  cannot  be  boiled. 

Novocain  in  ^  per  cent,  to  yV  per  cent,  solutions  is  said 
to  be  non-toxic,  and  is  not  deteriorated  by  boiling.  It  is  made 
up  in  normal  salt  solution,  often  with  the  addition  of  a  few 
drops  of  adrenalin  1  to  1000  to  the  ounce  of  mixture. 

Other  cocaine  derivatives,  stovain,  are  used  for  certain 
special  purposes. 

Urea  hydrochloride  in  1  per  cent,  to  ^  per  cent,  is  also  used 
for  local  anaesthesia. 

Indications:  Minor  operations,  enucleation  of  superficial 
tumors,  repair  of  hernia  in  the  adult,  and  many  major  operations 
where  general  anaesthesia  is  contraindicated.  Also  it  is  often 
used  in  conjunction  with  general  anaesthesia  to  avoid  shock. 

1.  Infiltration  ancesthesia  is  induced  by  injecting  the  solution 
into  the  skin  and  subsequently  into  each  tissue  layer  as  it  is 
exposed. 

2.  Regional  Ancesthesia. — The  area  of  operation  is  blocked 
off  by  deep  injection  of  the  solution  into  the  surrounding  tissues, 
and  in  some  cases  the  sensory  nerves  are  exposed  and  directly 
injected. 

3.  Spinal  Ancesthesia. — The  solution,  usually  stovain,  is 
injected  by  ''lumbar  puncture"  directly  into  the  subarachnoid 
space  of  the  spinal  canal.  It  permits  of  major  abdominal  and 
pelvic  operations  and  is  said  to  be  indicated  in  certain  cases 
where  general  anaesthesia  is  unsafe.  However,  there  is  con- 
siderable danger  of  serious  or  fatal  complications  even  when 
administered  by  an  expert. 

DEMONSTRATIONS 

1.  Types  of  accidental  wounds. 

2.  Condition  of  clean  wound  at  closure  and  at  first  dressing. 

3.  Stitch-abscess. 

4.  Demonstration  of  Carrel-Dakin  apparatus. 

5.  Method  of  preparing  an  accidental  wound  for  surgical  care. 

6.  Method  and  precautions  in  the  use  of  a  tourniquet. 

7.  AppHcation  of  a  pressure  bandage  to  control  hemorrhage. 

8.  Study  of  case  histories  cases  of  severe  hemorrhage  and  recovery. 

9.  Assembling  material  and  apparatus  for  operation  in  private  house. 

10.  Method  of  placing  patient  on  stretcher  and  transporting  from  bed  to 

ambulance,  arrangements  of  bottles,  blankets  or  special  sphnts. 

11.  Methods  of  preparation  for  operation,  and  for  transporting  to  operating 

room,  also  arrangement  of  patient  on  the  table. 

12.  Mechanism  of  operating  table,  change  of  position,  etc. 


70        ESSENTIALS  OF  SURGERY  FOR  NURSES 

13.  Assembling  and  preparation  of  apparatus  for  intravenous  infusion, 

hyperdermoclysis,  and  gastric  lavage. 

14.  Charts  and  methods  of  recording  blood-pressure  on  the  table. 

15.  Preparation  of  the  bed  for  return  of  patient,  with  special  positions,  and 

apparatus  for  drainage. 

16.  Methods  of  giving  enemas,  insertion  of  high  rectal  tube,  and  proctoclysis. 

17.  Position  and  methods  of  treatment  of  shock. 

18.  Preparation  for  and  method  of  catheterization. 

19.  Tray  and  necessary  supphes  for  dressing. 

20.  Technic  of  clean  dressing. 

21.  Care  of  "milk-leg." 

22.  Preparation  of  ether  mask  and  anaesthetist's  table. 

23.  Special  apparatus  for  anaesthesia,  ether  and  nitrous  oxide. 

24.  Local  anaesthesia,  apparatus,  and  preparation  of  solutions. 


EP/PN/S/S 


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CHAPTER  VI 
BONES  AND  ARTICULATIONS 
bones:    structuke,   infections^   tumors,   injuries 

A.  structure : — On  this  basis  bones  are  classified  in  three 
groups:  (1)  long  bones,  (2)  flat  bones,  and  (3)  irregular  bones. 

1.  Long  bones  (Fig.  8)  (example,  femur  or  humerus)  consist 
of  a  shaft  ("diaphysis")  and  two  enlarged  extremities  ("epiphy- 
ses")- The  development  of  the  bone 
is  characteristic,  with  a  principal 
"centre  of  ossification"  for  the 
shaft  or  diaphysis,  and  one  or  more 
"secondary  centres"  for  each  ex- 
tremity, or  epiphysis.  During  de- 
velopment each  epiphysis  is  sepa- 
rated from  the  diaphysis  by  a  layer 
of  special  hyaline  cartilage,  the 
"epiphyseal  cartilage"  in  which 
new  bone  is  formed  and  growth 
in  length  takes  place.  This  relation 
of  the  epiphyseal  cartilage  to  the 
epiphysis  and  diaphysis  persists 
throughout  childhood,  and  firm  bony 
union  occurs  in  various  bones  be- 
tween the  ages  of  sixteen  and  twenty- 
four,  after  which  growth  in  length 
ceases.  The  development  of  the 
epiphyseal  cartilage  is  significant 
from  a  practical  standpoint  for  the 
following  reasons : 

(a)  Growth  in  length  of  the  bone 
occurs  only  in  the  region  of  the 
epiphyseal  cartilage,  and  ceases  if 
this  be  destroyed  by  injury,  separation,  disease,  or  operation. 

(6)  Traumatic  separation  at  this  point  occurs  in  childhood, 
resembling  fracture. 

71 


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8. — Long  bone,  hvunerus. 


72        ESSENTIALS  OF  SURGERY  FOR  NURSES 


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Fig.  9. — Longitudinal  section  of  bone,  showing  structure. 

(c)  In  a  Rontgen  ray  examination,  the  secondary  centres  of 
ossification  appear  as  distinct  fragments  of  bone  and  may  be 
confused  with  a  displaced  fracture. 


BONES  AND  ARTICULATIONS  73 

(d)  The  blood  supply  of  the  epiphyseal  portion  is  inde- 
pendent from  that  of  the  diaphysis.  Therefore  certain  types  of 
infection  are  more  frequently  found  in  one  portion  and  tend  to 
remain  independent  of  the  other. 

2.  Flat  bones  include  the  scapula,  parts  of  the  pelvis, 
and  the  cranium.  They  develop  in  two  plates  from  layers 
of  fibrous  tissue,  and  are  therefore  called  "membrane"  bones. 
They  consist  of  two  bony  plates  of  compact  structure 
separated  by  an  intervening  layer  of  cancellous  bone  and 
marrow. 

3.  Irregular  bones  include  the  vertebrse  and  carpal  and 
tarsal  bones.  They  consist  of  masses  of  cancellous  bones  which 
are  rather  compact  on  the  surface. 

The  structure  of  bone  is  best  studied  in  a  longitudinal  section 
of  a  long  bone,  in  which  the  following  parts  call  for  attention 
(Fig.  9):  (a)  the  periosteum;  (6)  the  compact  outer  portion; 
(c)  cancellous  bone;  (d)  the  marrow  cavity. 

(a)  The  periosteum,  composed  of  dense  fibrous  tissue  with 
an  exceedingly  rich  vascular  supply,  surrounds  the  entire 
bone  except  for  the  articular  surface,  which  is  covered  with  hy- 
aline cartilage.  This  layer  carries  the  most  important  blood- 
supply  to  the  compact  bone  and  determines  its  nutrition,  also 
supplies  a  layer  of  underlying  "osteoblasts,''  the  bone-forming 
cells  which  produce  new  bone  in  early  development  and,  to  a 
greater  or  less  extent,  throughout  fife.  The  relations  of  the 
periosteum  are  of  practical  importance:  (i)  On  account  of  its 
density,  subperiosteal  swellings  (blood  or  pus)  are  retained  and 
cause  severe  pain,  (ii)  Separation  of  the  periosteum  from  the 
underlying  bone  by  blood,  pus,  or  injury  interferes  with  the 
nutrition  of  the  bone  and  often  causes  necrosis,  (iii)  Consider- 
able portions  of  a  bone  may  be  destroyed  by  disease  or  removed 
by  operation,  but  if  the  periosteum  with  the  underljang  osteo- 
blasts is  preserved,  regeneration  of  bone  takes  place  to  the 
extent  that  an  entire  structure  may  be  replaced. 

(6)  The  compact  outer  bony  part  lies  immediately  under  the 
periosteum,  represents  the  source  of  its  greatest  strength,  and  is 
the  most  recently  developed  part  of  the  bone. 

(c)  Cancellous  structure  is  present  to  a  greater  or  less  extent 
in  all  bones,  and  contains  interspaces  of  varying  size  in  which 
are  found  vessels,  nerves,  and  bone-marrow. 


74        ESSENTIALS  OF  SURGERY  FOR  NURSES 

{d)  The  marrow  cavity  forms  a  definite  space  in  all  long  bones 
and  contains  nutrient  vessels,  nerves,  fat,  and  certain  blood- 
forming  cells,  composing  the  marrow. 

B.  Infectious  lesions  of  bone,  "osteitis,"  occur,  as  in  other 
tissues,  from  wounds,  compound  fracture,  or  following  remote 
septic  processes  in  other  parts  of  the  body.  Examples:  Scarlet 
fever,  tonsillitis,  or  unrecognized  lesions.  The  process  may  be 
acute  or  chronic.  In  either  condition  the  infection  may  occur  as 
"osteomyelitis"  or  "periostitis." 

1 .  Osteomyelitis  refers  particularly  to  an  inflammatory  pro- 
cess which  involves  chiefly  the  marrow  cavity  and  the  central 
part  of  the  bone.  Effects:  Constitutionally  there  is  fever  and 
evidence  of  sepsis,  often  severe.  Locally,  there  is  pain  and  ten- 
derness, with  swelUng  when  the  process  is  advanced.  The  in- 
fection may  be  obscure  and  recognition  of  the  true  condition  is 
frequently  difficult.  It  is  often  mistaken  for  one  of  the  continued 
fevers — typhoid  or  rheumatism. 

Local  results:  (a)  Destruction  of  bone  and  the  production 
of  an  abscess  cavity  in  the  shaft  of  the  bone.  (6)  Considerable 
masses  of  necrotic  bone  slough  into  the  abscess  cavity,  form- 
ing a  "sequestrum."  (c)  A  sinus  is  formed  by  spontaneous 
rupture  to  the  surface  or  by  surgical  incision,  and  will  persist 
till  all  necrotic  material,  sequestrum,  is  removed  and  the  cavity 
is  entirely  filled,  id)  The  periosteum,  with  the  layers  of  osteo- 
blasts which  surround  the  suppurating  area,  develop  new  bone, 
forming  the  involucrum,  but  healing  is  never  completed  till  the 
sequestrum  and  all  septic  material  has  been  evacuated,  (e) 
Osteomyelitis  in  the  region  of  the  epiphysis,  occurring  in  child- 
hood, causes  destruction  of  the  epiphyseal  cartilage,  resulting 
in  permanent  shortening. 

The  course  except  in  occasional  virulent  infections  tends  to 
be  rather  subacute,  and  sinuses  may  persist  for  years,  being 
kept  open  by  the  presence  of  a  necrotic  sequestrum  with  a  pu- 
rulent discharge.  Indications  for  surgical  treatment,  i.e.,  in- 
cision and  evacuation  of  necrotic  material,  are :  (a)  To  evacuate 
pus  and  septic  material  and  relieve  constitutional  effects,  tox- 
aemia. (6)  To  prevent  further  destruction  of  healthy  bone, 
especially  when  the  process  is  in  the  region  of  the  epiphyseal 
cartilage,  (c)  To  remove  a  sequestrum  and  necrotic  material 
and  secure  closure  of  a  sinus. 


BONES  AND  ARTICULATIONS  75 

2.  Periostitis  refers  to  an  inflammatory  lesion  of  the  perios- 
teum and  underlying  compact  bone.  It  is  often  associated  with 
local  injury  as  a  causal  factor.  There  are  the  usual  constitutional 
effects  of  sepsis.  Locally  there  is  swelling  which  is  painful  on 
account  of  the  dense  periosteum,  and  recognition  of  the  nature 
of  the  condition  is  rather  easier  than  is  the  case  of  deep-seated 
lesions.  The  periosteum  is  separated  from  the  underlying  bone 
by  a  collection  of  purulent  material  which  leads  to  necrosis, 
and  spontaneous  rupture  to  the  surface  may  occur.  Indications 
for  surgical  treatment,  i.e.,  incision  and  evacuation  of  septic 
contents,  are  the  same  as  for  osteomyelitis. 

Chronic  infections  of  bone  include  two  types,  tubercular 
and  syphilitic. 

(a)  Tubercular  lesions  occur  most  often  in  children  and 
young  adults.  They  are  caused  by  the  tubercle  bacillus  derived 
from  other  lesions  within  the  body,  which,  however,  may  be 
remote,  and  the  bony  lesion  may  represent  the  only  active 
process.  The  focus  most  often  involves  the  epiphysis  of  the 
long  bones  and  tends  to  extend  to  the  adjacent  joint.  Consti- 
tutional effects  are  those  of  tuberculosis  and  are  important  aids 
in  reaching  a  diagnosis.  Results  are:  (i)  Destruction  of  bone 
and  epiphyseal  cartilage,  with  deformity  and  shortening  of  the 
bone,  (ii)  Destruction  of  articular  surfaces  and  "ankylosis" 
or  fixation  of  the  joint,  produced  by  the  fusion  of  the  articular 
surfaces,  (iii)  Development  of  an  abscess  from  which  a  sinus 
may  be  produced  by  spontaneous  rupture  or  surgical  incision, 
followed  by  secondary  infection  by  other  organisms.  The  irreg- 
ular bones,  carpals,  tarsals  and  vertebrae,  are  also  frequently 
involved  in  tubercular  processes. 

"Potfs  disease,"  tuberculosis  of  the  vertebral  column,  occurs 
more  often  in  children  but  is  occasionally  found  in  adults.  The 
causes  and  constitutional  results  are  the  same  as  those  of  surgi- 
cal tuberculosis  in  other  parts.  Results  are:  (i)  Destruction 
of  the  vertebrae  with  marked  deformity  of  the  spine,  ''kyphosis" 
or  "lordosis."  (ii)  Pressure  on  the  spinal  cord  as  a  result  of  de- 
formity of  the  body  of  the  vertebrae,  or  inflammatory  thickening, 
(iii)  Occasionally,  the  development  of  tubercular  meningitis, 
(iv)  Formation  of  abscesses  in  neighboring  tissues:  (1)  Retro- 
pharyngeal cellulitis  presenting  in  the  throat  from  the  cervical 
vertebrae.    (2)  "Psoas"   abscess   from   the    lumbar   vertebrae 


76        ESSENTIALS  OF  SURGERY  FOR  NURSES 

extends  in  the  sheath  of  the  psoas  muscle  and  tends  to  point 
about  Poupart's  ligament. 

Evidences  of  tubercular  disease:  (a)  General  reaction  of 
tuberculosis;  irregular  fever,  night  sweats,  loss  of  weight,  weak- 
ness, and  reaction  to  diagnostic  doses  of  tubercuhn.  (6)  Local : 
(i)  Pain  in  the  region  involved,  also  referred  pain  due  to  pressure 
on  nerve  trunks,  (ii)  Muscle  spasm  and  limitation  of  motion, 
thus  preventing  irritation  of  the  inflamed  articular  surfaces,  (iii) 
Night  pains  and  crying,  caused  by  the  relaxation  of  the  protec- 
tive muscle  spasm  during  sleep,  (iv)  Deformity  due  to  destruc- 
tion of  bone. 

The  early  history  of  bone  tuberculosis  is  usually  obscure. 
The  child  is  often  well  nourished  and  constitutional  disease  is 
not  suspected.  Local  symptoms  at  first  may  be  inconstant  and 
slight,  consisting  only  of  pain  and  some  limitation  of  motion. 
Examination  will  usually  show  some  deformity.  It  is  essential 
that  such  suspicious  cases  be  brought  to  the  surgeon  at  once 
to  secure  early  diagnosis  and  cure  with  a  minimum  of  deformity. 

Treatment. — (a)  Constitutional  measures  are  indicated  as  in 
other  tuberculous  processes,  and  must  be  followed  up  till  there 
is  no  evidence  of  the  disease.  (6)  Local  treatment  is  usually 
conservative,  the  general  principle  being  complete  and  pro- 
longed immobilization  of  the  affected  parts  by  means  of  plaster 
of  paris  cast,  or  special  apparatus.  This  prevents  irritation  of 
inflamed  tissues  and  promotes  healing.  Surgical  measures, 
excision  of  foci  of  infection  or  evacuation  of  abscesses,  are  re- 
served for  special  cases  and  indications :  (i)  When  the  epiphyseal 
cartilage  is  involved  or  threatened,  to  prevent  permanent 
shortening,  (ii)  In  certain  cases  in  adults  according  to  the 
judgment  of  the  surgeon,  (iii)  Under  special  conditions  a  col- 
lection of  purulent  material  may  advantageously  be  evacu- 
ated. Drainage  is  rarely  used  on  account  of  the  probability  of 
secondary  infection  and  the  development  of  a  persistent  sinus. 
Occasionally  the  cavity  is  filled  with  antiseptic  mixtures — • 
iodoform  oil,  formalin  in  glycerin,  or  bismuth  paste. 

(6)  Syphilitic  periostitis  consists  of  a  gumma  or  a  round 
cell  infiltration  of  the  sub-periosteal  tissues ;  suppuration  is  rare 
except  when  due  to  infection  following  exploratory  incision. 
There  is  severe  local  pain  which  is  characteristically  worse  at 
night,  local  swelling,  tenderness,  and  often  evidence  of  syphilis 


BONES  AND  ARTICULATIONS  77 

in  other  parts  of  the  body.  The  specific  tests  are  usually  positive. 
Treatment  is  constitutional.  The  practical  significance  lies  in 
the  fact  that  these  lesions  may  be  mistaken  for  suppurating 
periostitis,  and  so  treated. 

C.  Tumors  of  Bone. — There  are  two  main  groups  of  bone 
tumors:  (1)  Those  which  are  'primary  in  the  bone,  and  (2) 
metastatic  tumors  which  are  secondary  to  mahgnant  new- 
growths  in  other  regions  of  the  body. 

Primary  bone  tumors  include  those  derived  from  supporting 
tissues,  (a)  Osteoma  or  exostosis,  a  hard,  ivory-like,  slowly 
developing  process,  is  non-malignant.  (6)  Combinations  of 
bone  and  cartilage  or  connective  tissue,  tumors  which  are 
characterized  by  more  or  less  bone-destruction,  are  somewhat 
elastic,  and  often  degenerate,  forming  cysts  in  the  bones.  Such 
tumors  are  usually  non-malignant,  (c)  Various  types  of  sar- 
comas, including  the  giant-cell  sarcoma,  which  is  slowly  ma- 
lignant, and  the  small  round-cell  sarcoma,  and  those  derived 
from  the  lymph  and  blood-forming  tissues,  the  endothehoma, 
all  of  which  are  highly  malignant. 

The  presence  of  new-growth  is  made  evident  by  local  pain, 
swelling,  and  sometimes  by  spontaneous  fracture  when  there  is 
considerable  destruction  of  bone,  and  by  Rontgen  ray  exami- 
nation. The  exact  nature  of  the  tumor  and  its  degree  of  mahg- 
nancy  may  be  determined  to  a  certain  extent  by  the  rapidity 
of  its  growth,  the  X-ray  picture,  gross  appearance  on  explora- 
tory incision,  or  microscopic  examination  of  the  tissue. 

Principles  of  Treatment. — For  the  benign  tumors  or  those 
which  are  of  low  malignancy,  excision  of  the  tumor  with  a  wide 
margin  of  normal  tissue  may  be  sufficient.  For  the  malignant 
sarcomas,  amputation  well  above  the  level  growth  is  indicated 
at  the  earhest  possible  time,  but  recurrence  is  not  infrequent. 
Metastases  are  rarely  present.  Certain  non-operative  methods 
are  sometimes  used  for  advanced  inoperable  growths,  and  some- 
times delay  the  progress  or  occasionally  result  in  cure. 

2.  Metastatic  tumors  in  bone  are  always  secondary  to  some 
type  of  new-growths  in  other  parts  of  the  body.  They  may  be 
carcinoma  or,  less  often,  sarcoma.  Metastatic  new-growths 
are  usually  multiple,  involving  several  bones  in  various  parts 
of  the  body.  They  may  be  discovered  accidentally  as  in  case  of 
"spontaneous  fracture."     The  presence  of  several  new-growths 


78        ESSENTIALS  OF  SURGERY  FOR  NURSES 

in  bone  is  evidence  of  metastases,  and  that  the  original  tumor  is 
inoperable.  There  is  no  curative  treatment;  palliative  measures 
and  careful  nursing  is  all  that  is  possible. 

D.  Fractures. — A  fracture  is  a  break  in  the  continuity  of 
bones,  usually  the  result  of  violence,  which  may  be  (1)  direct, 
at  the  site  of  the  fracture,  or  (2)  indirect,  throwing  the 
breaking  strain  at  a  point  remote  from  the  application  of 
violence. 

Predisposing  causes  which  influence  the  type  and  frequency 
of  fracture  include:  (a)  Age.  The  bones  are  more  elastic  in 
childhood,  and  incomplete  fractures,  infractions  or  "green- 
stick  fractures, "  are  more  common. 

(b)  The  composition  of  bone  is  influenced  by  certain  con- 
stitutional diseases,  cretinism,  myxodema,  rickets,  and  a  few 
rare  conditions. 

Fractures  may  be  either  (1)  open  or  compound;  or  (2)  closed 
or  simple,  i.e.,  with  no  open  wound,  which  is  the  type  referred 
to  unless  otherwise  specified. 

1.  Open  or  compound  fractures  are  those  associated 
with  a  wound  of  the  overlying  skin  or  mucous  membrane.  The 
open  wound  may  be  produced:  (a)  By  the  violence  which 
caused  the  fracture.  (6)  By  a  splinter  of  bone  being  driven 
through  the  surface.  The  principal  dangers  of  a  compound 
fracture  are  infection  from  the  surface,  sepsis,  necrosis  of  bone, 
and  imperfect  union. 

2.  Closed  fractures  are  classified  according  to  the  nature 
of  the  break: 

(a)  Incomplete  "green-stick  fractures''  or  infractions  occur 
most  often  in  children,  whose  bones  are  more  elastic  and  not 
brittle.  There  is  deformity,  local  pain  and  tenderness,  and  ecchy- 
mosis,  but  no  separation  of  fragments  or  abnormal  mobility. 

(6)  Complete  fractures  may  be  oblique  or  transverse  across 
the  bone.  There  is  lateral  or  antero-posterior  displacement  of 
fragments,  and  often  injury  to  neighboring  soft  partte.  There  is 
deformity  and  abnormal  mobility  (Fig.  10). 

(c)  Spiral  fractures  occur  along  lines  of  cleavage  in  certain 
long  bones  due  to  twisting.  For  example,  falling  with  the  foot 
fixed  may  cause  a  spiral  fracture  of  the  femur,  tibia,  or  fibula. 
The  condition  may  be  obscure  and  treatment  is  difficult. 

(d)  A  comminuted  fracture  has  several  fragments  of  bone  and 


BONES  AND  ARTICULATIONS  79 

is  usually  the  result  of  a  crushing  injury.  There  is  considerable 
displacement,  deformity,  and  abnormal  mobility  (Fig.  16). 

(e)  An  impacted  fracture  is  one  in  which  the  fragments  are 
forced  together  by  the  violence  which  caused  the  fracture. 
There  may  be  deformity  but  no  abnormal  mobility. 

Associated  injuries  to  neighboring  structures  often  occur 
from  the  violence  which  caused  the  fracture  or  by  displaced 
fragments  of  bone. 

(a)  Dislocation  of  adjacent  joints  which  may  be  mistaken  for 
a  fracture. 

(6)  Muscles  or  their  tendons  are  often  torn  and  may  be 
interposed  between  fragments  of  bone,  thus  interfering  with 
apposition  and  proper  healing. 

(c)  Blood-vessels,  especially  veins,  are  frequently  lacerated, 
causing  the  accumulation  of  a  ''hsematoma,"  and  later  a 
deposit  of  blood  near  the  surface,  "ecchymosis,"  the  presence 
of  which  is  always  suggestive  of  fracture. 

(d)  Nerve  trunks  are  rarely  lacerated,  but  are  often  stretched 
so  that  fibres  are  torn,  resulting  in  temporary  disturbance  in 
sensation  or  weakness  of  certain  muscles.  Nerve  trunks  are 
occasionally  exposed  to  pressure  of  bony  fragments  or  callus 
formation,  resulting  in  permanent  disturbance  for  which  opera- 
tive treatment  may  be  necessary. 

Evidences  of  the  presence  of  fracture  are: 

(a)  Pain,  (i)  Local  pain  is  constant  till  the  deformity  is 
reduced  and  the  fragments  are  immobilized.  Further  persistence 
of  local  pain  indicates  imperfect  reduction,  or  immobilization, 
or  undue  pressure  from  dressings,  (ii)  Tenderness  or  acute 
pain  on  pressure,  if  persistent  and  definitely  localized,  is  ex- 
tremely suggestive  of  fracture  or  infraction. 

(6)  Ecchymosis,  which  appears  within  a  few  days  of  injury, 
is  evidence  of  damage  to  deep  structures,  especially  fracture. 

(c)  Deformity  and  abnormal  relations  of  bony  prominences 
or  landmarks  may  be  evident  on  casual  inspection,  or  be  dem- 
onstrated by  careful  measurement  and  comparison  with  normal 
parts. 

(d)  Crepitus,  which  is  produced  by  friction  of  fresh  bony 
surfaces,  may  be  felt  and  heard,  and  is  characteristic,  if  present. 
It  is  absent  in  incomplete  and  impacted  fractures,  also  in  those 
where  there  is  considerable  separation  of  fragments  or  inter- 


80        ESSENTIALS  OF  SURGERY  FOR  NURSES 

position  of  soft  parts.  Attempts  to  demonstrate  crepitus  are 
painful,  and  may  do  serious  damage  to  soft  parts,  or  break  up  a 
favorable  impaction. 

(e)  Abnormal  mohility  is  absent  in  infractions  and  impacted 
fractures.  It  causes  pain  and  there  is  danger  of  doing  further 
damage  to  surrounding  structures.  Often  it  can  be  demon- 
strated only  under  full  anaesthesia. 

(/)  Rontgen  ray  plates,  if  properly  taken,  determine  finally 
the  position  of  fragments  after  reduction.  Several  exposures 
from  various  angles  are  often  necessary  in  doubtful  instances. 

{g)  Examination  under  surgical  anaesthesia  is  of  value  in 
many  cases,  but  is  done  only  when  the  surgeon  is  prepared  to 
reduce  the  fracture  and  to  immobilize  it  in  a  permanent  dressing. 
There  is  serious  danger  of  causing  further  damage  by  vigorous 
manipulations  which  are  possible  under  anaesthesia. 

Process  of  Healing.— Provided  the  fragments  of  the 
fractured  bone  are  in  apposition  and  immobilized,  healing 
occurs  in  three  stages :  (a)  A  serous  or  bloody  exudate  is  poured 
out  about  the  fracture  as  in  wounds.  (6)  Bone  cells  develop 
from  the  fractured  ends  of  the  bone,  fprming  the  callus  which 
surrounds  the  area  of  the  fracture  as  a  spindle  shaped  enlarge- 
ment. This  is  visible  as  a  light  shadow  in  a  Rontgen  ray  plate, 
(c)  There  is  development  of  true  bone  giving  firm  union,  and 
absorption  of  the  excessive  callus.  If  apposition  and  immobili- 
zation have  been  good  there  remains  little  or  no  deformity  or 
evidence  of  previous  fracture.  The  time  required  for  complete 
healing  varies  for  different  bones.  It  increases  with  advancing 
age,  when  bone  formation  is  less  rapid.  Fairly  firm  union  is 
usually  present  in  from  two  to  six  weeks  in  children  and  from 
four  to  twelve  weeks  in  adults.  However,  at  least  double  this 
time  is  necessary  before  a  broken  bone  will  stand  weight-bearing, 
or  a  violent  strain. 

Principles  of  Treatment. — Closed  fractures:  First  aid 
should  provide  immobilization  to  relieve  pain  and  prevent  fur- 
ther damage.  Some  form  of  a  pillow  or  well  padded  splint 
can  be  secured  in  any  surroundings,  and  will  suffice  for  a  few 
hours  till  permanent  dressings  can  be  provided. 

The  aim  of  treatment  is  to  secure  firm  bony  union  and 
normal  function  without  deformity.  The  requisites  are:  (1) 
Reduction,  the  correction  of  deformity  and  bringing  the  bony 


BONES  AND  ARTICULATIONS  81 

fragments  into  accurate  normal  apposition  without  interven- 
tion of  soft  parts.  (2)  Immobilization  of  the  fragments  in  ap- 
position till  firm  bony  union  has  taken  place. 

(1)  Reduction  usually  requires  full  surgical  anaesthesia,  (a) 
on  account  of  pain,  and  (h)  to  secure  relaxation  of  voluntary 
muscles,  though  occasionally  simple  cases  with  shght  deformity 
may  be  reduced  without.  Apparatus  or  dressings  for  immobil- 
ization are  applied  at  once  after  reduction  to  maintain  the 
corrected  position.  In  case  of  doubt,  the  results  of  reduction 
are  checked  by  X-ray  pictures,  thus  disclosing  any  displacement, 
which  may  be  corrected  without  delay.  In  some  cases  where 
there  is  extensive  swelling,  temporary  immobilization  is  main- 
tained for  a  few  days  and  later  readjusted.  Reduction  and 
immobilization  is  impossible  in  certain  cases  of  extreme  dis- 
placement or  on  account  of  interposition  of  soft  parts,  and  in 
some  cases  the  corrected  position  can  not  be  maintained.  (2) 
Immobilization  is  maintained  by  various  types  of  rigid  dressing : 
(a)  Plaster  of  paris  casts  or  moulded  plaster  dressing;  (&) 
wooden  or  metal  splints,  padded,  and  held  in  place  by  adhesive 
plaster  or  bandage;  (c)  special  apparatus  designed  to  main- 
tain constant  counter-extension  in  certain  fractures.  Each 
form  has  particular  advantages  or  disadvantages  in  individual 
cases.  Various  surgeons  have  preferences  for  a  particular  style 
of  dressing  in  special  fractures  and  will  select  the  form  indicated 
in  each  instance.  All  of  the  necessary  material  must  be  on  hand 
and  ready  before  reduction  is  begun  in  order  that  no  time  be 
lost  while  the  patient  is  anaesthetized.  Several  strong  assistants 
are  needed  to  aid  in  reducing  the  fracture  and  maintaining  the 
corrected  position  till  the  support  is  in  place  and  set. 
A  satisfactory  dressing  should  hold  the  parts  immobilized 
in  accurate  apposition,  and  there  should  be  no  severe  pain 
after  the  first  few  hours.  Excessive  swelling  causes  pain,  but 
this  should  decrease  after  the  fracture  is  successfully  reduced 
and  put  up.  In  some  cases  where  there  is  excessive  swelUng, 
temporary  well-padded  dressings  are  applied  and  readjusted  as 
the  swelling  subsides.  If  a  plaster  cast  is  used,  it  may  be  split 
and  held  with  adhesive  strips  to  allow  for  swelling. 

Excessive  or  persistent  pain  indicates  undue  pressure  from 
dressings  and  should  have  the  attention  of  the  surgeon.  Hyp- 
notics must  be  used  with  care  since  the  pain  is  an  important 
6 


82        ESSENTIALS  OF  SURGERY  FOR  NURSES 

indication  of  serious  pressure.  This  may  (a)  interfere  with 
the  blood  supply  or  the  venous  return  from  dependent  parts, 
indicated  by  congestive  swelling  and  evidence  of  poor  circulation 
in  distal  parts,  i.e.,  fingers  or  toes;  (b)  cause  pressure  on  nerve 
trunks,  resulting  in  pain  and  later  paralysis  or  disturbance  in 
sensation.  Such  symptoms  are  an  indication  for  a  readjust- 
ment of  the  dressings  by  the  surgeon,  who  is  the  only  person  to 
interfere  with  them,  since  there  is  always  danger  of  loss  of  appo- 
sition, and  a  poor  result.  As  soon  as  firm  union  is  definitely  es- 
tablished, change  of  dressings,  massage,  or  passive  motion, 
under  direction  of  the  surgeon,  may  be  indicated,  especially  in 
adults,  to  prevent  stiffening  of  immobilized  joints  and  tendons, 
and  to  hasten  return  of  function. 

Open,  compound  fractuees,  are  complicated  by  accidental, 
probably  infected,  wounds.  In  addition  to  treatment  of  the 
fracture,  the  open  wound  calls  for  suitable  antiseptic  care — con- 
trol of  hemorrhage,  removal  of  foreign  or  necrotic  material,  and 
drainage.  Provision  must  be  made  in  the  cast  or  apparatus  for 
access  to  the  superficial  wound. 

Open  treatment  of  fractures  consists  of  exposure  of  the  fracture 
by  surgical  incision,  adjustment  of  the  fragments  under  direct 
vision,  and  the  use  of  special  means  of  immobilization.  The 
latter  may  be  accomplished  by  (a)  metal  screws,  nails,  or 
plates  fastened  to  the  bone,  or  (b)  bone  splints  obtained  either 
from  the  same  patient,  or  those  specially  prepared  and  pre- 
served. Such  operations  call  for  (a)  the  most  absolute  and 
rigid  aseptic  technique,  (6)  special  and  often  complicated 
apparatus,  and  (c)  extensive  experience  on  the  part  of  the 
surgeon  in  this  particular  work,  and  should  be  undertaken  only 
when  these  requisites  can  be  met.  Open  treatment  may  be  in- 
dicated: (i)  When  reduction  under  anaesthesia  is  for  any  reason 
not  possible,  (ii)  When  immobilization  in  apposition  cannot 
be  maintained,  (iii)  In  late  cases  when  closed  treatment  has 
given  bad  results,  (iv)  In  certain  special  fractures,  experience 
has  shown  that  good  results  are  rarely  obtained  by  ordinary 
methods,  and  open  treatment  is  that  of  first  choice.  Example: 
Fracture  of  the  patella. 

Results  of  treatment:  (a)  A  perfect  anatomical  result  is  the 
ideal.  There  is  no  deformity  or  shortening,  the  X-ray  shows  a 
normal  outline  of  bone,  and  there  is  perfect  function,     (h)  A 


BONES  AND  ARTICULATIONS  83 

perfect  functional  result  may  show  slight  deformity  or  anatom- 
ical imperfection,  but  is  acceptable  if  function  is  normal. 

Failures  or  Bad  Results. — (1)  Non-union  or  false  joint, 
with  abnormal  mobihty  may  be  due  to:  (a)  Failure  to  secure 
apposition  on  account  of  extreme  displacement  or  interposi- 
tion of  soft  parts,  (b)  Imperfect  immobihzation.  (c)  Sepsis  and 
necrosis  of  bone,  (d)  Local  disease  or  new-growths,  (e)  Consti- 
tutional disease,  rickets,  myxodema,  or  conditions  causing 
defective  new-bone  formation.  Such  results  may  call  for  open 
treatment  or  specific  medication. 

(2)  Excessive  deformity  may  be  caused  by  incomplete 
reduction,  or  loss  of  apposition  by  imperfect  immobilization, 
or  excessive  callus  production.  If  this  is  demonstrated  soon 
after  being  put  up,  it  can  often  be  corrected;  otherwise  open 
treatment  may  be  demanded. 

(3)  Persistent  pain,  paralysis,  or  atrophy  may  be  due  to: 
(a)  Injury  to  the  nerve  at  the  time  of  fracture  or  by  subse- 
quent manipulation,  (h)  Compression  of  a  nerve  trunk  by  tight 
dressing,  (c)  Pressure  or  involvement  of  the  nerve  in  the  healing 
of  a  fracture  or  callus  production.  Minor  injuries  to  a  nerve 
are  followed  by  temporary  disturbances  in  sensation  or  mus- 
cular weakness,  which  improve  with  rest,  massage,  and  electric 
treatment.  If  the  nerve-trunk  is  torn,  or  its  continuity  broken, 
suitable  operation  is  necessary  to  restore  function. 

(4)  Injury  to  Blood-vessels. — A  local  haematoma  from  lacer- 
ation of  a  vein,  less  often  from  an  artery,  causes  severe  pain  and 
swelling,  and  may  predispose  to  local  sepsis.  The  principal 
artery  to  an  extremity  (brachial  in  the  arm)  may  be  compressed 
by  a  tight  dressing  and  cause  gangrene  or  atrophy  of  dependent 
parts,  or  contraction  of  tendons  or  muscles,  with  serious  defor- 
mity. Warnings:  Severe  pain  or  premonitory  signs  of  deficient 
circulation  call  for  prompt  readjustment  of  the  dressings. 

(5)  Infection  and  sepsis  is  frequent  in  compound  fractures, 
and  is  an  important  complication  following  operative  treat- 
ment. It  occurs  rarely,  in  closed  comminuted  fractures,  with 
extensive  injury  to  soft  parts,  haematoma  formation,  or  the 
presence  of  necrotic  tissue  with  deficient  circulation. 

(6)  Stiffness  and  loss  of  function  is  more  frequent  in  adults 
or  those  of  advanced  age,  due  to  prolonged  immobilization  of 
joints  and  tendons. 


84        ESSENTIALS  OF  SURGERY  FOR  NURSES 

Special  Fractiires. — Those  of  the  face,  head,  vertebral  col- 
umn, and  thorax  will  be  considered  in  connection  with  those 
regions.  A  few  of  the  important  points  will  be  mentioned 
concerning  some  of  the  more  common  fractures. 

Upper  Extremity. — The  clavicle  is  most  often  fractured 
in  the  middle  third  by  indirect  violence,  a  fall  on  the  shoulder. 
The  deformity  is  characteristic,  the  shoulder  drops  forward  and 
is  rotated  inward.    It  is  corrected  by  being  drawn  upward  and 


Fig.  10. — Showing  spiral  fracture  of  the 
humerus  vnth  displacement. 


Fig.  11. — Showing  fracture  of  in- 
ternal condyle  of  humerus. 


outward,  being  held  in  the  corrected  position  by  adhesive 
straps.  Fracture  of  the  scapula  is  rare  except  from  crushing 
injury  or  gunshot  wounds.  Humerus  (Figs.  10,  11  and  12). — 
Fractures  are  classified  as  those  of  the  (1)  upper  third,  (2) 
middle  third,  and  (3)  lower  third  and  condyles. 

(1)  The  upper  third  includes  the  head,  anatomical  neck, 
and  the  ''surgical  neck,"  so-called  because  it  is  the  most  common 
site  of  fracture  in  this  region.     Fractures  of  the  upper  third 


BONES  AND  ARTICULATIONS 


85 


are  difficult  to  immobilize  in  correct  position.  There  is  often 
injury  to  the  circumflex  nerve  and  paralysis  of  the  deltoid 
muscle,  with  inability  to  raise  the  arm. 

(2)  Fractures  of  the  middle  third  are  often  oblique  or 
spiral,  with  considerable  displacement  of  fragments.  There 
may  be  involvement  of  the  "radial"  or  "musculo-spiral  nerve," 
with  paralysis  of  the  extensor  muscles  of  the  forearm  or  hand, 
and  characteristic  ''wrist-drop." 


Fig.  12. 


-Showing  spiral  fracture  of 
humenis. 


Fig.  13. — Showing  fracture  of  both 
bones  of  forearm  resulting  from  "direct 
violence." 


(3)  Fractures  of  the  lower  third:  (a)  Above  the  condyles 
displacement  is  usually  antero-posterior,  and  immobihzation 
may  be  difficult.  (6)  Those  of  the  condyles  and  elbow  are 
difficult  to  confirm  without  the  X-ray,  and  immobilization 
is  often  unsatisfactory  without  open  treatment.  Involvement 
of  the  ulnar  nerve  may  complicate  and  cause  paralysis. 

Forearm. — Fractures  of  the  radius  or  ulna,  or  of  both  bones 
in  the  upper  or  middle  thirds  (Fig.  13),  occur  most  often  from 


86        ESSENTIALS  OF  SURGERY  FOR  NURSES 

direct  violence  or  from  bending.  They  require  accurate  appo- 
sition and  perfect  inunobilization,  without  crowding  the  bones 
together,  since  there  is  danger  of  fusion  of  the  two  bones  and 
loss  of  function.  Fracture  of  the  lower  third  is  most  frequently 
the  "Colles's"  fracture,  which  involves  the  lower  end  of  the 
radius  and  at  times  the  tip  of  the  ulna. 

Wrist  and  Hand. — Fractures  of  the  carpal  bones  are  obscure, 
even  with  good  X-ray  plates.  If  overlooked  or  improperly  treated, 
these  often  result  in  permanent  deformity.     Fractures  of  the 


t-M 


Fig.  14. — Showing  fracture  of  the  neck  of  the  femur. 

metacarpals  and  phalanges  are  often  overlooked  without  X-ray 
examination,  being  of  the  "green-stick"  variety. 

Pelvis  and  Lower  Extremity. — Fractures  of  the  pelvis  result 
from  crushing  injury,  or  rarely,  difficult  obstetrical  delivery. 
They  usually  occur  lateral  to  the  S3rmphyses  pubes  and  the 
most  common  associated  injury  is  laceration  of  the  bladder  or 
urethra,  with  extravasation  of  urine  into  the  tissues.  There 
is  mobility  of  fragments  and  severe  pain  in  walking  or  movement. 
Fixation  of   fragments  is  secured  by  tight  bandage  or  open 


BONES  AND  ARTICULATIONS 


87 


operation.     Repair  of  associated  injury  may  present  the  most 
urgent  indication. 

Femur. — Fracture  of  the  neck  occurs  most  often  during  adult 
hfe  or  advanced  age  (Fig.  14).  Reduction  and  immobilization 
in  apposition  is  difficult,  open  operation  being  occasionally 
necessary.  There  is  danger  of  non-union  and  permanent  disa- 
bility.    Prolonged  inmiobilization  in  a  special  cast  or  apparatus, 


Fig.  15. — Showing  fracture  of  the  patella. 


Fig.  16. — Showing  "  comminuted  frac- 
ture" of  the  tibia. 


usually  in  bed,  carries  serious  danger  of  hypostatic  pneumonia, 
especially  in  the  aged.  Fractures  of  the  shaft  of  the  femur  are 
often  obHque,  spiral,  or  splintered,  with  marked  displacement. 
They  are  difficult  to  reduce  and  require  special  apparatus  for 
counter-extension,  to  overcome  muscle  resistance  and  to  pre- 
vent shortening. 

The  Patella  or  "Knee-cap"  is  fractured  by  direct  violence 


88        ESSENTIALS  OF  SURGERY  FOR  NURSES 

(Fig.  15),  blows  or  falling.  It  is  practically  impossible  to 
maintain  fixation  of  fragments  without  open  operation,  which 
is  the  method  of  first  choice. 

Leg. — The  tibia  or  fibula  is  fractured  by  crushing  injury 
(Figs.  16,  17  and  18)  or  by  falling  with  the  foot  fixed,  and  is 
frequently  compound.  Accurate  alignment  and  apposition  are 
essential.     Poor   results   often   occur   from  too  early  weight- 


FiG.    17. — Showing  transverse   fracture 
of  the  tibia  with  "callus  formation." 


Fig.  18. — Showing  an  "incomplete 
fracture' '  infraction  or ' '  green-stick ' '  fract- 
ure of  the  tibia. 


bearing.  "Pott's  fracture"  involves  the  lower  end  of  the  fibula 
and  at  times  the  internal  maleolus  of  the  tibia.  It  is  the  one 
most  frequently  seen  in  this  region  and  demands  accurate  posi- 
tion and  prolonged  protection  from  weight-bearing.  Fracture 
of  the  tarsals,  metatarsals,  and  phalanges  are  always  obscure, 
and  are  usually  confirmed  only  by  the  X-ray. 


BONES  AND  ARTICULATIONS 


89 


ARTICULATIONS. 

From  a  surgical  standpoint,  articulations  are  limited  to  the 
synarthroses,  or  movable  joints  (Fig.  19).  (See  Anatomy.) 
The  articular  surfaces  of  the  bones  involved  are  covered  with 
hyaline  cartilage.  A  capsule  enclosing  the  joint-cavity  is 
attached  about  the  ends  of  the  component  bones.  It  is  com- 
posed of  (a)  dense  fibrous  tissue,  reinforced  by  special  ligaments, 


coryLO/D  UG. 


CAPSULE 


FAT 


ROaA/D  Z/^ 


OBTURATOR 
MEMBRANE 


Fig.  19. — Showing  structure  of  articulation. 

and  (6)  synovial  lining,  composed  of  endothelial  cells,  secretes 
the  synovial  fluid  to  lubricate  the  articular  surfaces  and  prevent 
friction. 

There  are  three  considerations  of  interest,  swellings,  in- 
fections, and  injuries. 

Swellings  are  usually  due  to  ''effusion"  or  increase  of  the 
synovial  fluid,  which  may  be  caused  by  (1)  injury,  irritation, 
and  (2)  infection.    It  causes  pain,  limitation  of  motion,  and 


90        ESSENTIALS  OF  SURGERY  FOR  NURSES 

swelling  which  is  evident  on  inspection  or  by  special  examina- 
tion. If  persistent,  there  follows  relaxation  of  the  supporting 
ligaments,  and  a  permanently  weak  joint.  Treatment:  Immobil- 
ization by  a  suitably  padded  splint  or  bandage  prevents  irrita- 
tion from  motion  and  allows  absorption  of  the  fluid.  Local 
counter-irritants  and  analgesics  may  be  of  value:  Iodine  or 
arnica,  with  hot,  moist  compresses.  Persistence  of  swelling  or 
evidence  of  infection  may  be  indication  for  more  radical 
measures. 

'^ As-piration"  (withdrawal)  of  the  fluid  with  a  needle  and 
syringe  under  aseptic  precautions  is  done  for  one  of  two  reasons: 

(1)  Diagnosis,  to  determine  the  nature  of  the  fluid,  (a)  Clear 
fluid  is  usually  the  result  of  injury  or  mechanical  irritation, 
and  is  often  absorbed  with  immobilization  of  the  joint.  (6)  Pus 
or  bacteria,  as  demonstrated  by  microscopical  examination, 
indicates  infection  and  may  call  for  radical  surgical  treatment. 

(2)  For  Treatment:  (a)  Withdrawal  of  clear  fluid  to  relieve 
pressure  is  usually  followed  by  spontaneous  cure.  (6)  To  inject 
antiseptic  solutions,  iodoform  oil,  or  formalin  in  glycerin,  in 
infected  cases. 

•Infections  may  occur  in  two  forms:  (1)  Acute  suppuration 
from  injury  or  complicating  infectious  processes  in  other  parts 
of  the  body.  There  is  high  fever  and  constitutional  effects  and 
marked  local  swelling,  pain,  and  destruction  of  tissue.  Surgi- 
cal measures:  Evacuation  of  necrotic,  septic  material,  and  the 
use  of  strong  antiseptic  irrigations.  Drainage  is  rarely  used. 
(2)  Chronic,  tubercular  processes  result  as  extension  from 
component  bones.  Destruction  of  cartilage  often  causes  anky- 
losis and  loss  of  function. 

Injury  and  Irritation. — (1)  Dislocation  involves  a  lacer- 
ation of  the  fibrous  capsule,  through  which  the  articular  end 
of  one  of  the  bones  protrudes  and  is  held  by  muscular  contrac- 
tion. There  is  (a)  pain,  (6)  characteristic  deformity  which 
cannot  be  reduced  by  direct  pressure,  and  (c)  limitation  of  mo- 
tion. There  is  no  crepitus  or  abnormal  mobility.  The  condition 
is  often  confused  with  fracture,  which  may  also  be  present. 
Reduction  requires  special  manipulation  to  bring  the  dislocated 
bone  into  normal  relations.  Anaesthesia  is  usually  necessary  to 
overcome  muscle  contraction.  Prolonged  immobilization  is 
needed  to  allow  healing    of   the  capsule.     Recurrence  is  not 


BONES  AND  ARTICULATIONS  91 

infrequent  on  account  of  the  relaxation  of  the  capsule.  Com- 
plications include:  Fracture  of  component  bones;  injury  to  soft 
parts;  stiffness  and  limitation  of  motion. 

(2)  Sprains  and  minor  injury  to  joints  result  in  laceration 
of  the  capsule  or  tendons.  There  is  pain  and  swelling,  which  are 
increased  by  use.  Such  inj  ury  requires  prolonged  immobilization 
and  support  by  a  suitable  bandage  or  cast.  There  is  always 
danger  of  missing  a  fracture,  and  X-ray  examination  is  needed 
promptly  in  doubtful  cases. 

Loose  bodies,  "joint  mice,"  result  from  fragments  of  artic- 
ular cartilage  or  folds  of  synovial  membrane  which  are  separated 
by  injury  and  become  calcified.  Such  a  condition  is  character- 
ized by  recurrent  attacks  of  pain,  swelling,  and  limitation  of 
motion.  The  knee  joint  is  most  frequently  involved.  Surgical 
removal  is  necessary  for  cure. 

The  bursce  are  sacs  lined  with  a  synovial  membrane,  and 
sometimes  are  continuous  directly  or  indirectly  with  an  adja- 
cent joint.  They  are  located  under  or  between  muscle  tendons 
and  prevent  friction  over  bony  prominences.  Bursse  become 
thickened,  swollen,  and  painful  as  a  result  of  injury,  persistent 
irritation,  or  infection,  resulting  in  serious  limitation  of  motion. 
Surgical  treatment,  excision  or  evacuation  of  contents,  is 
indicated  in  certain  cases.  Examples:  Prepatellar  bursitis 
(''Housemaid's  Knee"),  the  bursse  about  the  elbow,  or  shoulder 
joint. 

DEMONSTKATIONS 

1.  X-ray  plate  showing  elbow  of  child  to  show  secondary  centres  of  ossi- 

fication. 

2.  Demonstrate  or  discuss  in  detail  a  specific  case  of  osteomyehtis  with 

sinus  formation,  and  have  one  of  class  report  on  the  operative 
findings  and  subsequent  history. 

3.  Demonstration  of  X-ray  plate  taken  to  show  regeneration  of  bone 

several  months  after  resection. 

4.  X-ray  plates  showing  localized  tuberculosis  of  bone,  tumors,  and  cysts. 

5.  X-ray  plates  showing  various  types  of  fracture :  green-stick,  complete, 

spiral,  comminuted,  and  impacted. 

6.  X-ray  plate  taken  after  reduction,  showing  apposition  and  callus. 

7.  Demonstration  of  "pillow-splints"  and  various  "first-aid"  dressings. 

8.  Demonstration  of  special  apparatus  and  splints  for  immobihzation. 

9.  X-ray  of  late  case  showing  marked  deformity. 

10.  Instruments  and  apparatus  for  open  treatment  of  fractures. 


CHAPTER  VII 
VASCULAR,   LYMPHATIC,  AND   NERVOUS   SYSTEMS 

The  Vascular  System  includes  arteries,  veins,  and  capillaries. 
The  student  should  also  review  the  physiology  of  the  systemic, 
pulmonary,  and  portal  circulation. 

Arterial  System. — From  a  surgical  standpoint,  we  have  to 
consider:  Collateral  blood-supply,  aneurism,  and  transfusion  of 


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Fig.  20. — Superior  mesenteric  artery  showing  anastomoses  and  terminal  branches. 

blood.  The  arteries  carry  blood  to  the  tissues  of  the  body,  and 
interference  with  the  normal  supply  cuts  off  the  oxygen  and 
nutrition  to  the  part  involved.  A  ''principal  artery"  (example, 
brachial  to  the  arm)  is  the  chief  source  of  supply  to  a  given  region. 
1.  Collateral  circulation,  composed  of  vessels  of  inde- 
pendent origin,  and  also  anastomoses  between  branches  given 
92 


VASCULAR  AND  LYMPHATIC  SYSTEMS 


93 


off  the  principal  artery  at  different  levels,  furnishes  an  auxil- 
iary blood-supply  to  most  regions  of  the  body  (Fig.  5,  page  26,  and 
Fig.  20).  A  terminal  artery  is  one  which  constitutes  practically 
the  sole  blood  supply  to  a  special  region,  with  no  collateral  or 
auxiliary  circulation. 

Principles :    Complete  occlusion,  by  hgation  or  embolus,  of  a 


POPL/rSALAPf 


Fig.  21. — Popliteal  aneurism. 

terminal  artery  usually  causes  gangrene  or  necrosis  of  the  depen- 
dent tissues.  If  the  principal  artery  be  gradually  occluded  from 
any  cause,  collateral  branches  and  anastomoses  compensate  to 
a  greater  or  less  extent,  the  dependent  tissues  receive  some 
blood,  and  gangrene  may  be  avoided,  or  will  involve  only  the 
most   dependent  parts.    Example,  toes.     If  the  occlusion  be 


94        ESSENTIALS  OF  SURGERY  FOR  NURSES 

gradual  and  the  collateral  circulation  abundant,  compensation 
will  be  adequate.  Sudden  complete  occlusion  (ligation)  of  a 
principal  artery,  except  at  certain  points,  does  not  allow  for 
compensatory  development  of  collateral  circulation,  and  more 
or  less  atrophy  or  gangrene  is  unavoidable. 

2.  Aneurism  (Fig.  21). — This  is  a  localized  dilatation  of  an 
artery  due  to  weakening  of  the  wall  as  a  result  of  disease.  The 
aneurism  may  be  sharply  circumscribed,  "saccular,"  or  "dif- 
fuse." The  condition  is  of  most  interest  in  the  larger  vessels, 
aorta,  axillary,  or  the  principal  branches,  though  it  may  be 
present  in  any  artery.  There  results  a  thin-walled  tumor  which 
pulsates  actively  with  each  heart-beat.  Pain  is  marked,  due  to 
the  intermittent  pressure.  Rupture  and  hemorrhage  are  the 
most  serious  complications,  and  finally  cause  fatal  loss  of 
blood.  The  presence  of  an  aneurism  may  interfere  with  adequate 
blood  supply  to  dependent  parts.  The  pulsating  tumor  often 
erodes  solid  structures,  bone  or  cartilage,  with  which  it  comes 
in  contact  and  causes  great  pain. 

Treatment  includes:  (a)  Palliative  measures  to  prevent 
rupture,  specific  and  constitutional  treatment  to  reduce  blood- 
pressure,  influence  local  disease,  or  promote  spontaneous  coag- 
ulation of  the  contents  and  obliteration  of  the  sac.  (6)  Curative 
surgical  procedures :  Ligation  of  the  vessel  above  or  below  the 
sac,  possibly  also  excision  or  reconstruction  of  the  aneurism, 
introduction  of  silver  wire  into  the  sac,  with  or  without  electricity 
to  promote  coagulation  and  obliteration  of  the  aneurism. 

3.  Transfusion  of  blood  refers  to  the  transferring  of  whole 
blood  from  the  vessels  of  one  individual  to  those  of  another. 
Indications  include:  (a)  Sudden  severe  hemorrhage,  (i)  To 
supply  volume  of  blood  and  raise  the  blood-pressure,  and  insure 
adequate  circulation  to  the  brain  and  vital  centres.  The  cause 
of  death  in  immediately  fatal  cases  of  hemorrhage  is  anemia  of 
the  brain  due  to  low  general  blood-pressure,  (ii)  To  furnish 
blood  elements  which  are  deficient  as  a  means  to  control  certain 
types  of  hemorrhage,  (iii)  To  overcome  the  resulting  anemia. 
(6)  In  certain  diseases  (example,  pernicious  anemia  and  chronic 
infections),  for  therapeutic  effect  aside  from  the  anemia. 

Methods. — (a)  Direct,  the  artery  of  the  "donor"  is  brought 
into  direct  continuity  with  the  open  vein  of  the  patient,  either 
by  means  of  suture  of  the  ends  or  sides  of  the  vessels  to  each 


VASCULAR  AND  LYMPHATIC  SYSTEMS         95 

other  or  by  special  canulas.  The  whole  blood  is  allowed  to 
flow  directly  from  one  individual  to  the  other.  (6)  Indirect 
transfusion,  blood  is  withdra^^Ti  from  the  veins  of  the  ''donor" 
and  injected  into  the  veins  of  the  patient  by  means  of  syringes 
or  special  apparatus.  The  greatest  difficulty  is  coagulation  of 
blood  in  the  needles  or  canulas,  which  is  sometimes  overcome 
by  the  addition  of  certain  substances  (sodium  citrate,  0.2% 
solution. 

Veins. — Thrombosis,  varicose  veins,  and  phlebotomy. 

1.  Thrombosis  refers  to  the  coagulation  of  blood  within 
a  blood-vessel,  usually  a  vein,  resulting  in  the  occlusion  of  that 
vessel.  Causes:  (a)  Local  infectious  processes  cause  throm- 
bosis in  adjacent  veins  which  may  extend  to  large  vessels. 
Example:  Middle  ear  or  mastoid  infections  cause  thrombosis 
in  the  jugular  or  lateral  sinus  of  the  brain.  (6)  Remote  septic 
processes  or  systemic  infections,  typhoid,  (c)  Local  lesions  or 
injuries,    varicose    veins,    hemorrhoids,    pressure    of    tumors. 

(d)  Post-operative  or  puerperal  thrombosis  occurs  in  remote 
vessels  even  when  there  is  no  apparent  evidence  of  sepsis. 

(e)  Constitutional  changes  may  be  an  indirect  causal  factor. 
Location:  Except  in  cases  adjacent  to  local  infection,  throm- 
bosis occurs  most  often  in  the  iliac  or  femoral  vein,  and  because 
of  certain  anatomical  influences,  is  more  frequent  on  the  left 
side.  It  is  commonly  spoken  of  as  "milk  leg"  or  by  the  surgeon 
as  ''phlegmasia  alba  dolens,"  hterally,  painful  white  swelling. 

Effects  and  Dangers. — (a)  Occlusion  of  the  lumen  of 'the 
vein,  interfering  with  the  return  of  venous  blood,  and  swelling 
of  the  limb.  (6)  Pain  on  account  of  the  distention  of  the  tissues, 
(c)  Danger  that  a  portion  of  the  clot  may  be  dislodged  and 
carried  as  an  embolus  in  the  circulation,  especially  to  the  heart 
or  brain,  with  fatal  results,  (d)  Later  there  is  partial  re-estab- 
lishment of  the  circulation  by  absorption  of  the  clot  and  devel- 
opment of  collateral  vessels,  (e)  A  persisting  tendency  to 
varicose  veins  and  swelling.  The  duration  is  from  one  to  two 
weeks.  There  is  fever  from  100°  to  103°,  with  swelling  of  the 
limb,  pain,  and  tenderness  in  the  thigh. 

Principles  of  Treatment. — Absolute  rest  in  bed  and  complete 
immobilization  of  the  limb  is  necessary  to  prevent  separation 
of  fragments  of  the  clot.  A  cradle  or  support  for  the  bedding 
should  be  used  to  protect  the  limb.    Local  application  of  sooth- 


96        ESSENTIALS  OF  SURGERY  FOR  NURSES 

ing  lotions  (lead  and   opium)    or  salves  (belladonna),  ^vith  a 
well-padded  flannel  bandage,  are  of  value  to  relieve  pain. 

2.  Varicose  VEINS  consist  of  dilated  tortuous  and  distended 
veins.  The  condition  is  found  most  often  in  special  regions  where 
the  veins  are  poorly  supported  by  surrounding  tissues,  i.e.,  sub- 
cutaneous and  submucous,  and  where  the  vessels  support  a  long 
column  of  blood:  internal  saphenous,  hemorrhoidals,  or  sper- 
matics;but  the  term  usually  refers  to  the  condition  in  the  limbs. 

Causes. — (a)  A  partial  interference  with  the  flow  of  blood  by 
the  pressure  of  tumors  or  masses,  or  remains  of  thrombi. 
(6)  Heart  lesions  with  venous  congestion,  (c)  Occupations 
requiring  prolonged  standing,  weakening  of  the  vessel  walls, 
repeated  distention,  and  loss  of  tone  in  surrounding  tissues. 

Course  and  Complications. — The  condition  is  persistent  and 
tends  to  increase  in  extent.  The  tissues  become  honeycombed 
with  distended  veins.  The  dependent  tissues  are  passively 
congested  and  have  decreased  resistance  to  injury  or  infection 
on  account  of  poor  blood-supply,  thus  explaining  the  tendency 
to  varicose  leg  ulcers.  Rupture  of  a  distended  vein  to  the  surface 
with  sharp  hemorrhage  is  not  uncommon.  Thrombosis  of  the 
varicose  vessels  with  infection  occurs  especially  in  hemorrhoids. 

Treatment. — Palliative  measures  consist  of  supports  to  the 
part  by  means  of  elastic  stockings  or  a  pressure  bandage  of 
canton  flannel.  These  give  considerable  relief  and  improve 
the  local  circulation,  but  are  in  no  sense  curative.  Surgical 
measures  include  a  variety  of  procedures :  (a)  Excision  of  the 
principal  veins  involved.  (6)  Ligation  of  the  larger  veins.  Re- 
sults are  usually  good. 

3.  Phlebotomy,  literally  opening  a  vein,  may  be  done: 
(a)  By  means  of  a  sharp  aspirating  needle  introduced  through 
the  skin  into  one  of  the  superficial  veins  of  the  forearm,  made 
prominent  by  a  pressure  bandage  or  light  tourniquet  above. 
(6)  The  vein  is  exposed  by  dissection  under  local  anaesthesia 
and  a  canula  introduced.  Blood  may  be  withdrawn  in  small 
amounts  for  bacteriologic  study  or  special  tests,  or  in  larger 
amounts  for  therapeutic  reasons.  Substances  may  be  intro- 
duced into  the  veins  in  special  treatments :  blood  in  transfusion, 
saline  or  similar  solutions,  drugs  (salvarsan). 

Lymphatic  system,  in  relation  to  infections  and  malignant 
disease, 


VASCULAR  AND  LYMPHATIC  SYSTEMS         97 

L  Infections. — (a)  Acute  processes  (see  page  12).  Septic 
material,  bacteria,  and  toxines  from  local  lesions  are  taken  up, 
first  by  the  lymph  vessels,  and  reaches  the  neighboring  l3rmph- 
nodes.  Example:  from  the  mouth  to  the  submaxillary  nodes. 
These  structures  hypertrophy  and  enlarge  in  the  attempt  to 
destroy  toxines  and  bacteria,  thus  preventing  further  extension. 
There  are  two  possible  courses:  (i)  Favorable;  spontaneous  reso- 
lution. The  process  is  overcome  in  the  early  stage  through  control 
of  the  primary  focus  by  incision  and  adequate  'drainage,  before 
the  lymph-nodes  break  down  and  suppurate.  In  this  event  the 
secondary  involvement  of  the  lymph-nodes  subsides,  though 
there  may  remain  some  enlargement,  (ii)  Unfavorable; 
suppuration  of  the  lymph  glands  may  take  place  from  con- 
tinued absorption  of  septic  material  from  the  primary  focus. 
This  is  evident  in  superficial  nodes  by  softening  and  fluctuation. 
After  this  has  occurred,  spontaneous  resolution  rarely  follows 
and  this  focus  must  be  considered  as  an  independent  septic 
abscess.  Treatment  is  directed  to  the  primary  focus  if  this  be 
accessible,  and  also  to  the  lymph-nodes  themselves. 

(b)  Chronic  infection  of  the  lymph-nodes  is  usually  tuber- 
cular (see  page  36),  and  is  secondary  to  such  lesions  either  in  the 
tributary  tissues  or  adjacent  nodes.  It  occurs  most  often  in 
children  or  young  adults  and  involves  the  cervical,  retro-peri- 
toneal, or  pulmonary  nodes,  surgical  interest  being  limited  to 
the  cervical  or  inguinal  glands.  Suppuration,  when  present,  is 
usually  due  to  secondary  infection.  Constitutional  evidence 
of  tuberculosis  is  generally  present. 

Principles  of  Treatment. — (a)  Specific  and  constitutional  for 
tuberculosis.  (6)  Local  apphcations  and  ointments  are  of 
slight  value,  (c)  Surgical  incision  and  evacuation  of  contents 
in  advanced  stages  with  suppuration,  (d)  Excision  of  involved 
glands  in  selected  cases. 

2.  In  relation  to  Malignant  Disease  (see  page  43). 
Involvement  of  lymph-nodes  which  are  palpably  enlarged  oc- 
curs early  in  malignant  disease  (cancer).  When  present,  this  is 
evidence  that  the  process  is  no  longer  localized,  but  has  spread. 
Radical  operation  in  all  cases  must  include  extensive  dissection 
and  removal  en  masse  of  the  tributary  lymph-nodes,  but  the 
prognosis  is  not  as  favorable  if  the  tributary  lymph-nodes  are 
involved. 
7 


98        ESSENTIALS  OF  SURGERY  FOR  NURSES 


THE  NERVOUS   SYSTEM. 
This  is  considered  under  the  following  headings: 


The  Central  Nerv- 
ous   System 
Cerebro-spinal 


i  Brain  ^  Meninges  and  Cerebro-spinal  Fluid. 
\  Cerebrum,  Cerebellum,  and  Pons  Varolii. 
Spinal  Cord. 

B.  Peripheral  Nervous  System  {gj^^^tS^^^ 

A  consideration  of  the  anatomical  structure  and  relations 
requires  a  review  of  anatomy  and  physiology  which  is  not  pos- 

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Fig.  22. — Structure  of  motor  neurone. 


sible  to  cover  in  this  course.     Only  a  few  of  the  more  important 
considerations  will  be  mentioned. 

The  Neurone  (Fig.  22)  or  nerve  cell  represents  the  essential 
structural  and  functional  unit  of  the  entire  nervous  system. 
A  neurone  consists  of  a  cell  body  with  its  protoplasm  and 
nucleus,  and  certain  processes:  the  short,  many-branched 
"dendrites"  (1),  and  the  single   "axis-cylinder  process"  (2). 


NERVOUS  SYSTEM 


99 


In  general  the  dendrites  receive  nerve  impulses  from  various 
sources  and  transmit  them  toward  the  cell  (afferent),  and  the 
axis-cylinder  process  transmits  nerve  impulses  away  from  the 
cell  (efferent).  The  life  and  function  of  the  processes  depend  on 
the  neurone.  Division  of  the  fibre  or  destruction  of  the  cell- 
body  results  in  complete  degeneration  and  loss  of  function  of  the 
peripheral  portion  of  the  process,  including  dependent  structures, 
muscles,  or  sensory  apparatus.  If  the  cut  ends  are  brought  into 
contact  there  results  a  regeneration  of  nerve  fibres  and  later  a 
return  of  function.     Such  regeneration  occurs  also,  provided 

fI  ROLANDO  P/fOJ£CnO/V       ^ 


Fig.  23. — Cerebral  cortex. 

the  cut  peripheral  end  is  brought  into  contact  with  the  central 
ends  of  axis-cylinder  processes  of  any  origin. 

Nerve  cells  are  located  in  the  "grey  matter"  which  is  found 
in  various  regions  of  the  central  nervous  system.  For  example  : 

1.  The  Cerebral  cortex  (Fig.  23)  contains  two  main 
groups  of  cells,  (a)  Association  cells,  whose  axis-cylinder  pro- 
cesses give  communication  between  various  areas  of  the  brain. 
Destruction  of  such  cells  causes  no  well-defined  motor  or 
sensory  disturbances  and  these  regions  are  therefore  called 
"silent  areas."  (6)  Projection  cells,  whose  axis-cylinder  pro- 
cesses communicate  with  neurones  at  lower  levels  which  give. 


100      ESSENTIALS  OF  SURGERY  FOR  NURSES 

rise  to  motor  nerves,  or  receive  sensory  stimuli  from  definite 
regions.  Destruction  or  lesions  of  such  areas  cause  well-defined 
effects  characteristic  for  the  region  involved. 

2.  The  Grey  matter  of  the  Spinal  cord  contains  a  special 
group  of  motor  neurones  at  various  levels  in  the  "anterior  horns." 


Fig.  24. — Showing  relations  of  upper  and  lower  segment  neurones.  Upper  segment: 
R.  and  L.,  right  and  left  cerebral  cortex;  1,  projection  motor  neurone  and  fibre  to  anterior 
horn  cell,  A;  2,  projection  sensory  fibre  fron  centre  in  cord;  3,  association  fibre.  Lower 
segment:  R.  L.,  right  and  left  cord.  A,  anterior  horn  motor  cell  and  motor  nerve 
fibre;  B,  posterior  root  sensory  cell  and  sensory  nerve  fibre. 

These  cells  are  under  the  influence  of  the  projection  fibres  from 
the  "motor  area"  of  the  opposite  side  of  the  cerebral  cortex, 
and  their  axis  cyhnders  make  up  the  motor  fibres  of  the  periph- 
eral spinal  nerves.  This  represents  the  voluntary  control  of 
motor  and  other  functions  exercised  by  the  brain,  and  is  lost 


NERVOUS  SYSTEM  101 

through  (a)  destruction  of  the  higher  centres,  or  (b)  injury  or 
break  in  continuity  of  the  "upper  segment"  axis-cylinder 
process. 

3.  The  Sensory  fibres  of  the  peripheral  spinal  nerves  arise 
from  a  special  group  of  neurones  located  in  the  "posterior  root 
ganglions  "  at  various  levels  of  the  cord.  These  neurones  have  a 
peculiar  type  of  axis-cylinder  process  which  divides  into  two 
branches:  (a)  Passes  to  the  periphery  and  goes  to  form  the 
sensory  portion  of  the  peripheral  nerve,  cranial  or  spinal;  (b) 
passes  to  the  cord  and  transmits  sensory  afferent  impulses  to 
the  cord  and,  by  means  of  several  communicating  neurones, 
to  the  cerebral  cortex,  where  it  is  received  as  a  conscious  sen- 
sation. Destructive  lesions  may  occur  in  either  the  "upper 
segment"  or  "lower  segment." 

(1)  The  Upper  Segment  (Fig.  24)  includes:  (a)  The  cerebral 
cortex  (i)  motor  areas;  result  in  a  characteristic  type  of  par- 
alysis of  certain  regions  on  the  opposite  side  of  the  body.  The 
"reflexes"  are  not  abolished  and  may  be  increased,  (ii)  Sensory 
areas;  cause  disturbance  in  sense  perception  referred  to  the 
opposite  side  of  the  body.  (6)  To  the  tracts  of  projection  fibres 
lower  in  the  brain  or  cord  cause:  (i)  Paralysis  at  lower  levels, 
more  or  less  diffuse,  with  increased  reflexes;  (ii)  sensory  dis- 
turbances at  lower  levels,  also  diffuse. 

(2)  Lower  Segment  (Fig.  24),  involving  the  motor  or  sensory 
cells  in  the  cord  or  their  axis-cylinder  processes,  cause:  (a) 
Motor  paralysis  with  loss  of  reflexes;  (6)  more  or  less  localized 
sensory  disturbances.  Lesions  of  the  peripheral  nerves  cause 
mixed  motor  and  sensory  disturbances. 

Special  Regions  of  the  Central  Nervous  System 
Central:    1.    Meninges    and    Cerebro-spinal    Cavity    and 
Fluid.     2.  Brain.     3.  Spinal  Cord. 

Peripheral:     1.  Cranial  Nerves.     2.  Spinal  Nerves. 

CENTEAL  NERVOUS  SYSTEM 

The  Meninges  include:  (a)  Dura  mater,  (6)  pia  mater, 
(c)  arachnoid,  which  enclose  the  entire  central  nervous  system. 
The  dura  mater  is  a  dense  fibrous  structure,  adherent  to  the 
cranium,  and  carries  the  meningeal  arteries,  also  the  "venous 
sinuses"  formed  by  folds  or  layers  of  the  dura,  carrying  blood 
from  the  brain  to  the  jugular  veins. 


102      ESSENTIALS  OF  SURGERY  FOR  NURSES 


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Fig.  25. — Showing  relations  of  the  cerebro-spinal  spaces. 


NERVOUS  SYSTEM  103 

In  the  vertebral  column  the  dura  is  attached  by  several 
ligamentous  processes,  but  is  not  adherent  to  the  bone.  The 
pia  mater  is  a  delicate  structure  immediately  adherent  to  the 
brain  or  cord,  and  carries  a  group  of  blood-vessels  supplying 
the  underlying  tissue.  The  arachnoid  membrane  is  interposed 
between  the  dura  and  pia  enclosing  the  subarachnoid  space  and 
the  cerebro-spinal  fluid.  The  meninges  are  highly  susceptible  to 
infection,  "meningitis."  This  may  occur  as  a  spontaneous 
disease  due  to  various  bacteria  (example,  epidemic  meningitis, 
or  tubercular),  or  as  an  acute  septic  meningitis  complicating 
operative  or  accidental  wounds,  the  latter  form  usually  being  a 
rapidly  fatal  process. 

The  Cerebro-spinai.  fluid  is  a  clear  substance  contained 
within  the  sub-arachnoid  space  of  the  brain  and  spinal  cord, 
the  cerebro-spinal  canal,  and  ventricles  of  the  brain  (Fig.  25). 
The  cerebro-spinal  space  (see  anatomy)  includes  the  ventricles 
of  the  brain  and  the  central  canal  of  the  spinal  cord.  It  commu- 
nicates with  the  sub-arachnoid  space  by  means  of  foramina 
(openings)  in  the  roof  of  the  fourth  ventricle  in  the  region  of 
the  medulla.  The  cerebro-spinal  fluid  is  derived  from  the  blood 
in  the  venous  plexuses  of  the  ventricles  of  the  brain,  and  is 
absorbed  from  the  sub-arachnoid  space,  thus  maintaining  a 
constant  equilibrium.  Functions. — (a)  The  fluid  is  concerned 
with  the  distribution  of  nutrition,  and  waste-products  of  oxi- 
dation in  the  central  nervous  system.  (6)  Mechanically  the 
fluid  forms  a  water  bed  protecting  the  delicate  nervous  tissue 
from  injury,  and  serves  to  equalize  pressure  on  any  part  of 
the  brain.  Example:  Increased  pressure  within  the  skull  is 
compensated  to  some  extent  by  an  increase  in  pressure  of  the 
cerebro-spinal  fluid  in  the  sub-arachnoid  space  of  the  spinal 
cord,  as  may  be  determined  by  "lumbar  puncture." 

Lesions  associated  with  abnormal  distribution  of  the  cere- 
bro-spinal fluid:  Hydrocephalus  consists  of  a  dilatation  of  the 
ventricles  of  the  brain  with  cerebro-spinal  fluid  under  increased 
pressure,  resulting  in  a  compression  of  brain  substance.  It 
usually  occurs  in  the  new-born  or  young  children  and  causes  en- 
largement of  the  bony  cranium  and  separation  of  the  individual 
bones,  resulting  in  characteristic  shape  of  the  head  (Fig.  26). 

The  causes  are:  (a)  Disturbed  relationship  between  the 
formation  and  absorption  of  the  cerebro-spinal  fluid,  or  (6) 


104      ESSENTIALS  OF  SURGERY  FOR  NURSES 

obstruction  which  prevents  the  normal  distribution  of  the  fluid, 
resulting  in  accumulation  in  the  ventricles.  Results:  Compres- 
sion of  the  cerebrum,  distention  of  the  skull,  protrusion  of  the 
eyes,  corneal  ulcer,  blindness,  headache,  restlessness,  destruc- 
tion of  brain  substance,  with  idiocy  or  mental  deficiency,  and 
usually  death.  Recovery  is  rare,  though  the  process  may  be 
arrested  spontaneously  or  as  result  of  treatment,  but  is  likely 
to  leave  evidence  of  mental  impairment. 


Fig.  2G. — Hydrocephalus. 

Principles  of  Treatment. — Little  can  be  done  to  correct  the 
cause  in  most  cases.  Palliative  measures :  Withdrawal  of  fluid 
by  aspiration  of  the  ventricle  relieves  symptoms  temporarily, 
or  in  rare  instances,  permanently.  Various  operative  procedures 
to  provide  a  permanent  channel  by  which  the  cerebro-spinal 
fluid  may  reach  other  regions  and  be  absorbed  have  been  sug- 
gested and  are  occasionally  successful  in  providing  permanent 
relief;  they  nevertheless  involve  extensive  surgical  procedures 
carrying  a  high  mortality,  and  the  results  are  rarely  satisfactory. 


NERVOUS  SYSTEM  105 

Lumbar  Puncture. — The  cerebro-spinal  canal  may  be  reached 
clinically  by  means  of  pmicture  with  an  aspirating  needle, 
introduced  between  the  lumbar  vertebrae  into  the  sub-arach- 
noid space  of  the  cord. 

PuEPOSES. — (1)  Diagnosis,  (a)  To  determine  the  pressure  of 
the  cerebro-spinal  fluid ;  (6)  for  chemical  or  microscopical  exami- 
nation of  the  fluid;  (c)  special  diagnostic  tests.  (2)  Treatment. 
(a)  To  withdraw  fluid  in  case  of  increased  intracranial  pressure; 
(6)  to  introduce  serum  or  drugs  in  specific  diseases  or  menia- 
gitis;  (c)  for  anaesthesia  by  the  introduction  of  special  sub- 
stances in  the  sub-arachnoid  space. 

Dangers. — (1)  Infection  and  septic  meningitis  in  spite  of 
all  aseptic  precautions.  (2)  Disturbances  in  intracranial 
pressure  by  the  withdrawal  of  a  considerable  amount  of  fluid, 
or  increased  pressure  by  injection  of  fluid  or  serum.  (3)  Injury 
to  the  cord  is  usually  avoided  by  making  the  puncture  between 
the  lower  lumbar  vertebrae,  below  the  level  of  the  cord. 

The  Brain,  including  the  cerebrum,  cerebellum,  and  pons 
Varolii  is  best  considered  as  a  single  structure  with  certain 
regions  or  centres  where  lesions  cause  definite,  well-recognized 
effects.  These  special  projection  regions  include:  (1)  Parts  of  the 
cerebral  cortex,  the  motor  and  sensory  areas  about  the  fissure  of 
rolando,  and  other  regions  concerned  in  the  ''special  senses," 
sight,  hearing,  and  smell  (Fig.  23) .  (2)  Lesions  of  the  cerebellum 
cause  definite  effects,  disturbances  in  equilibrium,  which  are 
fairly  characteristic  when  carefully  studied.  (3)  The  medulla 
oblongata,  which  contains  centres  for  the  vital  functions,  car- 
diac, respiratory,  vasomotor,  and  also  for  certain  of  the  cranial 
nerves,  shows  characteristic  and  serious  disturbances  from 
lesions  of  any  sort.  For  this  reason  injury  or  hemorrhage  at 
the  base  of  the  skull  causing  pressure  on  the  medulla  is  followed 
promptly  by  disturbances  in  blood-pressure,  heart-beat,  and 
respiration  with  early  loss  of  consciousness  or  death.  Further- 
more, this  region  is  not  accessible  to  surgical  approach  and 
rehef  as  is  the  region  of  the  cortex.  Other  regions  of  the  brain 
are  regarded  as  ''silent  areas"  since  there  are  no  definite  char- 
acteristic effects  of  irritation  of  destructive  lesions  which 
enable  the  surgeon  or  neurologist  to  locate  the  area  involved. 

Lesions  of  the  brain  from  injury,  infection,  or  new-growth 
cause  two  groups  of  effects: 


106       ESSENTIALS  OF  SURGERY  FOR  NURSES 

(A)  Special,  depending  on  the  irritation  or  injury  of  defi- 
nite areas  controlling  particular  muscles,  functions,  or  regions 
through  projection  axones.  (1)  Irritation  causes  convulsions 
or  epileptic  seizures,  always  beginning  in  a  definite  group  of 
muscles,  and  in  severe  cases  terminating  [in  temporary  loss  of 
consciousness,  constituting  "petit  mal"  or  "Jacksonian  epi- 
lepsy." (2)  Destructive  lesions  cause  paralysis  of  definite 
regions,  disturbances  of  sensation,  or  loss  of  function.  A  careful 
study  of  these  effects  enables  the  neurologist  to  locate  the  spe- 
cial area  of  the  brain  involved. 

(B)  General  effects  of  lesions  of  the  brain  are  largely  due 
to  increased  intracranial  pressure  and  disturbance  in  the  cere- 
bral circulation.  The  cranial  cavity  is  non-expansible,  and  the 
brain  itself  is  not  compressible,  so  there  is  no  provision  for 
compensation  of  a  sudden  increase  of  the  contents  of  the  skull, 
i.e.,  hemorrhage,  depressed  fracture,  rapidly-growing  tumor,  or 
abscess.  The  effects  of  increased  intracranial  pressure  vary 
somewhat  according  to  the  cause,  but  are  fairly  characteristic. 
These  are:  (1)  Faintness,  stupor,  or  unconsciousness  in  marked 
cases,  and  finally  death  due  to  disturbance  in  cerebral  circu- 
lation. (2)  Severe  and  persistent  headache,  may  be  intermittent 
in  early  cases.  (3)  Stertorous  breathing  associated  with  coma 
or  unconsciousness.  (4)  Bradycardia,  abnormally  slow  heart- 
beat, about  50  per  minute.  (3  and  4  are  especially  evident  in 
traumatic  cases.)  (5)  Persistent  vomiting,  irrespective  of  tak- 
ing food,  may  be  intermittent.  (6)  Eye  changes,  especially  in 
gradually  developing  cases,  degeneration  of  the  optic  nerve, 
shown  by  ophthalmoscopic  examination,  and  finally  blindness. 
(7)  Increased  systolic  blood  pressure. 

Surgical  Lesions  of  the  brain  include:  (A)  Trauma,  (B) 
Infections,  (0)  Tumor. 

(A)  Trauma. — Injury,  blows  to  the  skull,  may  cause  dis- 
turbances of  the  brain  by  (1)  '^  Concussion.'^  There  is  no  fract- 
ure or  external  sign  of  injury,  nor  are  there  any  gross  lesions 
of  the  brain  itself.  There  is  temporary  disturbance  of  intra- 
cranial pressure  and  the  cerebral  circulation,  with  possibly 
slight  hemorrhage  due  to  rupture  of  small  vessels.  The  clinical 
evidences  are:  Temporary  loss  of  consciousness  which  persists 
for  a  few  minutes  or  hours;  gradual  improvement  which  is 
progressive  and  finally  complete,  followed  by  persistent  head- 


NERVOUS  SYSTEM  107 

ache  for  a  few  days.  Failure  of  the  condition  to  clear,  or  an 
increase  in  the  symptoms,  is  evidence  of  more  serious  injury, 
intracranial  hemorrhage  or  fracture. 

Treatment  is  essentially  expectant,  i.e.,  restjin  bed,  possibly 
with  restraint,  ice-bag  to  the  head,  and  careful  observation. 

(2)  "Contusion"  of  the  brain,  with  actual  injury  to  brain 
substance,  may  be  due  to :  1.  Laceration  by  depressed  fragments 
of  fractured  skull.  2.  Sudden  pressure  due  to  hemorrhage  from 
meningeal  vessels,  or  less  often,  from  cerebral  arteries. 

1.  Depressed  skull  fractures  are  usually  evident  on  careful 
examination,  though  there  may  be  extensive  injury  to  the  brain 
with  few  external  signs.  There  is  usually  associated  intra- 
cranial hemorrhage.  The  effects  are:  (a)  Local,  depending  on 
the  area  of  the  brain  involved,  (i)  Paralysis,  (ii)  Sensory 
disturbances,  (iii)  Respiratory,  cardiac,  or  vasomotor  changes 
from  lesions  of  the  medulla.  (6)  General  effects  of  increased 
intracranial  tension:  Coma,  unconsciousness,  stertorous 
breathing,  slow  pulse,  headache,  vomiting,  high  blood-pressure. 

Principles  of  Treatment — ^Palliative  measures  and  expectant 
observation  in  doubtful  cases,  or  Surgical  Exploration :  Eleva- 
tion of  depressed  fragments,  control  of  hemorrhage,  evacuation 
of  clots,  and  relief  of  pressure.  In  properly  selected  cases  this 
procedure  often  proves  to  be  a  life  saving  measure,  being  fol- 
lowed by  prompt  return  to  consciousness. 

2.  Sudden  intracranial  hemorrhage,  due  to  trauma,  may 
occur  with  or  without  friacture,  and  with  no  external  evidence 
of  severe  lesion.  It  is  usually  from  the  middle  meningeal  artery 
and  occurs  outside  of  the  dura,  though  rarely  it  occurs  from 
other  sources.  There  are  marked  local  pressure  effects  and  in- 
crease of  intracranial  pressure  which  is  characteristic.  The 
effects  are  local  and  general  as  in  other  brain  lesions :  (a)  Local, 
depending  on  the  special  area  involved,  often  affecting  the 
motor  region.  (6)  General:  There  is  initial  unconsciousness 
which  is  persistent  in  the  more  severe  cases,  but  often  clears 
within  a  few  hours.  The  typical  picture  shows  this  temporary 
improvement  and  then  a  gradual  development  of  signs  of  in- 
creasing intracranial  pressure:  Slow  pulse,  headache,  vomiting, 
drowsiness  and  developing  coma,  with  stertorous  breathing. 
The  history  and  course  is  characteristic,  and  all  cases  with  head 
injury  must  be  followed  carefully  for  evidence  of  increasing 


108      ESSENTIALS  OF  SURGERY  FOR  NURSES 

intracranial  pressure,  since  early  operative  relief  is  urgently 
indicated  in  properly  selected  cases. 

Principles  of  Treatment. — Evidence  of  traumatic  hemorrhage 
is  indication  for  surgical  exploration  over  the  middle  meningeal 
artery:  (a)  To  relieve  intracranial  pressure  and  remove  clots; 
(6)  to  control  bleeding.  The  prognosis  is  good  in  simple  cases 
which  are  given  prompt  reUef.  Apoplexy:  Spontaneous 
hemorrhage  from  cerebral  vessels  is  less  frequent  except  where 
there  is  preexisting  disease  of  the  arteries.  It  causes  destruction 
of  brain  substance,  but  is  usually  not  accessible  to  surgical 
relief. 

(B)  Surgical  Infections  of  the  Brain: 

(1)  Septic  meningitis  comphcating:  (a)  Surgical  operations 
on  the  brain  or  cord;  (6)  accidental  perforation  of  the  meninges 
in  operation  on  the  mastoid,  frontal  sinus,  or  nose;  (c)  acci- 
dental wounds  or  compound  fractures.  The  process  is  usually 
virulent  and  rapidly  fatal,  being  influenced  but  slightly  by 
treatment. 

(2)  Brain  abscess  is  usuallj^  secondary  to  septic  processes  in 
neighboring  structures,  to  which  the  body  has  developed  some 
degree  of  immunity.  Therefore  a  brain  abscess  may  be  chronic 
in  its  course,  and  cause  considerable  destruction  of  tissue  vnth. 
but  little  constitutional  effects. 

Causes. — (a)  Septic  wounds  of  the  scalp,  infection  being 
carried  by  perforating  l;^Tiiphatics  or  veins.  (6)  Compound 
fractures,  (c)  Infection  in  the  middle  ear,  mastoid,  frontal,  or 
nasal  sinuses. 

Course. — Except  in  the  cases  associated  wdth  septic  menin- 
gitis, there  is  gradual  development  and  slight  constitutional 
effects.  The  temperature  is  often  subnormal,  and  the  pulse 
slow.  Headache  is  marked  and  persistent.  There  is  evidence  of 
a  gradually  increasing  intracranial  tension  and  later  signs  of 
exhaustion.  The  condition  may  extend  or  rupture  into  the 
ventricles  or  free  meningeal  space,  resulting  in  increase  of  sepsis 
and  death. 

Recognition  of  a  brain  abscess  is  often  difficult  except  when 
the  history  is  suggestive.  Surgical  treatment :  Exposure  of  the 
cavity,  evacuation  of  contents,  and  drainage  are  possible  when 
the  abscess  can  be  located  and  is  accessible,  but  the  prognosis 
is  never  bright. 


NERVOUS  SYSTEM  109 

(C)  TtTMORS  OR  NEW-GROWTHS  are  most  often  primary  and 
are  derived  from  the  supporting  tissues.  Some  of  the  more 
common  types  include:  (1)  Osteoma,  developing  from  the 
cranial  bones  often  at  the  site  of  a  fracture.  (2)  Ghoma,  from 
the  supporting  cells  of  the  nervous  tissues.  (3)  Fibrous 
growths  from  the  meninges.  (4)  Angiomata  of  various  types, 
from  the  vascular  tissues  of  the  brain.  (5)  Sarcoma,  developing 
from  one  of  the  above  sources.  (6)  Infectious  masses,  syph- 
ilitic or  tubercular. 

The  course  is  slow  and  obscure  in  the  early  part  of  the  proc- 
ess    Effects  are  (1)  local,  and  (2)  general. 

1.  Local  effects  are  evident  only  when  special  areas  of  the 
brain  are  involved :  motor  centre,  spnsory  regions,  special  sense 
areas,  the  medulla,  and  nuclei  of  the  cranial  nerves. 

2.  General  symytoms  are  due  to  a  gradually  increasing  intra- 
cranial pressure,  and  maybe  months  or  even  years  in  develop- 
ing :  (a)  Headache,  at  first  periodic  and  later  persistent.  (6)  Eye 
symptoms;  abnormalities  in  color  vision,  and  later  failure  of 
vision  and  blindness.  Ophthalmoscopic  examination  of  the 
eye-grounds  early  in  the  process  shows  definite  changes  in  the 
retina  and  degeneration  of  the  optic  nerve,  (c)  Vomiting,  with 
no  relation  to  eating,  {d)  Finally,  periods  of  stupor.  In  this 
connection  it  should  be  emphasized  that  certain  s;>Tiiptoms — 
intense  periodic  headache,  attacks  of  vomiting  without  apparent 
cause,  or  disturbances  in  vision — developing  over  a  short  period 
of  time,  call  for  thorough  examination  by  a  competent  neu- 
rologist or  ophthalmologist.  By  follo"v\dng  this  course  it  will 
be  possible  in  certain  cases  to  make  an  early  diagnosis  and  offer 
reasonable  hope  of  relief  by  suitable  operation. 

Treatment  is  entirely  surgical:  (a)  Craniotomy,  ''decom- 
pression" to  reheve  intracranial  pressure  and  relieve  symp- 
toms; headache,  vomiting,  and  failing  vision.  (6)  Removalofthe 
tumor  in  cases  where  it  can  be  located  and  is  accessible,  or  as  a 
second  stage  following  decompression. 

The  Pituitary  body  situated  at  the  base  of  the  brain  in  the 
"sellum  turcica"  is  occasionally  of  surgical  interest,  and  is 
best  considered  in  connection  with  the  brain.  Function:  It  is  a 
glandular  structure  and  provides  an  internal  secretion  which  is 
important  in  the  early  development  of  the  body — bones,  sub- 
cutaneous fat,  and  sexual  organs — and  has  a  marked  influence 


no      ESSENTIALS  OF  SURGERY  FOR  NURSES 

on  body  metabolism.  Surgical  interest  is  confined  to  tumors  or 
enlargements  associated  with  destruction  of  the  gland.  Results 
are:  (a)  Mechanical,  pressure  on  neighboring  structures;  optic 
nerve,  disturbance  of  vision,  venous  sinuses,  and  increase  of 
intracranial  pressure.  (6)  Developmental  disturbances,  due 
to  abnormal  secretion:  Enlargement  of  certain  bones,  skull, 
long  bones  of  hands  and  feet,  overdevelopment  of  fat,  mental 
changes,  drowsiness  or  stupor,  loss  of  sexual  characteristics, 
and  disturbances  of  metabolism.  The  development  of  the 
clinical  picture  is  gradual  and  inconstant.  Recognition  of  the 
condition  is  confusing  and  the  diagnosis  can  only  be  made  by 
expert  observation.  Operation,  removal  in  selected  cases  by  a 
skilled  surgeon,  offers  a  fair  prospect  for  marked  improvement. 

3.  The  Spinal  Cord. — This  structure  is  composed  of  two 
distinct  portions,  each  having  separate  functions.  A.  White 
MATTER,  consisting  of  columns  of  nerve  fibres  which  communi- 
cate: (1)  Between  various  brain  centres  and  the  cells  of  origin 
of  the  peripheral  nerves  in  the  cord;  (2)  between  neurones  at 
various  levels  of  the  cord.  B.  Grey  matter  (Fig.  27),  which 
contains:  (1)  Motor  cells  whose  axis-cylinder  processes  form 
the  motor  fibres  of  the  peripheral  nerves;  (2)  intermediate 
cells  whose  processes  communicate  between  different  levels 
of  the  cord  or  carry  sensory  impulses  to  the  brain.  (3)  Pos- 
terior root  ganglia  are  not,  anatomically,  a  part  of  the  cord, 
but  are  located  in  connection  with  the  posterior  root  of  the 
peripheral  nerves.  The  axis-cylinder  process  is  bifurcated,  one 
branch  making  up  the  sensory  part  of  the  peripheral  nerve,  the 
second  passing  to  the  cord  and  transmitting  sensory  impulses 
directly  or  indirectly  to  the  brain. 

Lesions  of  the  cord  may  affect  either  the  white  matter  or 
the  grey  matter,  or  more  often  are  combined.  (1)  Lesions  of  the 
white  matter  disturb  the  various  communicating  tracts  of  nerve 
fibres,  and  the  effects  are  less  definite  than  when  the  grey  matter 
is  involved.  Extensive  or  complete  transverse  lesions  cut  off 
communication  between  the  brain  and  nerve  cells  or  secondary 
centres  at  lower  levels  in  the  cord.  Certain  disturbances  are 
common:  (a)  Loss  of  "tissue  tone,"  development  of  trophic 
ulcers,  and  bed-sores.  (6)  Loss  of  control  of  the  bladder  and 
rectum,  with  incontinence  of  urine  and  faeces.  These  effects 
often   cause  serious   complications,   which  fact  renders  the 


NERVOUS  SYSTEM  111 

prognosis  of  serious  injury  to  the  cord  extremely  grave  unless 
the  cause  can  be  promptly  removed.  (2)  Lesions  of  the  grey 
matter  cause  destruction  of  a  group  of  motor  cells  and  degenera- 
tion of  the  corresponding  motor  nerve  with  paralysis.  Injury 
to  the  posterior  root  ganglions  cause  sensory  disturbance. 
Since  the  centres  are  arranged  in  a  definite  manner  and  give 
origin  to  segmental  nerves  with  a  definite  distribution,  it  is  pos- 
sible to  determine  the  location  of  a  lesion  by  study  of  the  dis- 
tribution of  resulting  disturbances,  motor  or  sensory.  (3) 
Most  lesions  of  the  cord  involve  both  white  and  grey  matter, 
and  the  effects  are  therefore  combined.    That  is,  there  are: 


SENSORY 
NEURONE 


POSTimOff 
SEA/SOff/ROOr 


CENTffAL  CANAL        koTOR  NEURONE    ^l^f^^fgQj- 

Fig.  27, — Spinal  cord  and  origin  of  peripheral  spinal  nerve  fibres. 

(a)  Motor  and  sensory  disturbances  in  the  area  supplied  by 
the  peripheral  nerves  which  originate  at  the  level  of  the 
lesions.  (6)  A  variety  of  trophic,  motor,  and  sensory  disturb- 
ances due  to  injury  to  communicating  tracts. 

Surgical  lesions  of  the  cord  may  be  caused  by:  (1)  injury, 
(2)  disease,  or  (3)  tumor. 

1.  Injury  from  depressed  fracture  of  the  vertebral  column 
may  cause  lacerations  of  the  cord  or  compression.  When  it  is 
possible  to  locate  the  level  of  the  lesion  by  the  distribution  of 
the  motor  and  sensory  abnormality,  surgical  measures,  elevation 
of  fragments  and  rehef  of  pressure,  are  indicated.  Prompt  treat- 
ment may  result  in  complete  recovery.  Hemorrhage  associated 


112       ESSENTIALS  OF  SURGERY  FOR  NURSES 

with  fracture  does  not  cause  as  severe  effects  as  that  within 
the  skull. 

2.  Deformity  and  curvature  of  the  spine  due  to  disease  and 
necrosis  of  the  vertebrae,  tuberculosis,  ''Pott's  disease,"  may 
cause  serious  pressure,  or  this  may  be  due  to  extension  of  the 
process  and  thickening  of  the  meninges.  Treatment  of  these 
cases  can  only  be  directed  to  correct  the  deformity  and  reheve 
the  pressure  on  the  cord.  Certain  infections,  acute  anterior 
poliomyelitis,  cause  destruction  of  the  motor  cells  of  the  cord, 
with  permanent  paralysis  of  the  muscles  supplied  by  the  corre- 
sponding motor  nerves. 

3.  Tumors  occurring  in  relation  to  the  spinal  cord  are  of  the 
same  origin  as  those  of  the  brain.  The  effects  are  gradual  in 
their  development,  but  a  careful  neurological  study  will  often 
locate  the  level  of  the  lesion.  Surgical  removal  and  relief  of 
pressure  is  possible  in  many  cases. 

PERIPHERAL   NERVOUS   SYSTEM 

Cranial  nerves  include  the  twelve  pairs  of  special  nerves 
given  off  from  nuclei  in  the  brain: 

1.  Olfactory,  nerve  of  smell,  injured  in  lesions  or  opera- 
tions on  the  upper  nasal  passage. 

2.  Optic,  nerve  of  sight.  Involved  in  atrophy  by  increased 
intracranial  pressure,  compressed  by  tumors  of  the  base  of  the 
brain  or  the  pituitary  body. 

3.  OcuLO-MOTOR,  also  concerned  in  control  of  the  pupil. 
Affected  by  lesions  about  the  medulla  or  base,  causes  squint, 
loss  of  reflex  to  hght,  and  unequal  pupils, 

4.  Trochlear,  to  eye  and  upper  hd,  paralysis  causes  droop- 
ing of  upper  lid. 

5.  Trifacial,  sensory  nerve  to  the  face,  nose,  mouth,  and 
throat,  and  motor  to  the  muscles  of  mastication.  It  is  of  most 
interest  in  connection  with  "trifacial  neuralgia,"  the  cause  of 
which  is  indefinite  or  unknown.  The  condition  is  persistent  or 
recurrent  and  is  associated  with  spasmodic  excruciating  pain 
in  the  region  supplied  by  one  or  more  branches  of  the  nerve. 
Surgical  treatment  aims  to  destroy  the  branches,  or,  in  extreme 
cases,  to  destroy  or  remove  the  ganghon  of  the  nerve,  (a)  by 
injecting  the  nerve  through  one  of  the  foramina  (bony openings), 
v/here  it  leaves  the  skull,  with  alcohol  or  other  agent.  (6)  Inject 


NERVOUS  SYSTEM  113 

the  ganglion  where  the  cells  of  origui  are  located,  through  the 
proper  foramen,     (c)  Surgical  removal  of  the  ganglion. 

6.  Abducens  nerve,  motor  to  the  external  rectus  of  the 
eye,  is  involved  in  lesions  of  the  base  of  the  brain,  and  causes 
disturbances  in  the  movements  of  the  eyeball. 

7.  Facial,  motor  to  the  muscles  of  expression  of  the  face. 
It  is  involved  in  lesions  of  the  medulla,  petrous  part  of  the 
temporal  bone,  internal  ear,  and  mastoid  process,  resulting  in 
paralysis  of  the  muscles  of  expression,  with  typical  deformity. 

8.  Auditory  nerve,  involved  in  lesions  of  the  medulla, 
base  of  the  brain,  temporal  bone,  causes  permanent  deafness  on 
that  side. 

9.  Glosso-pharyngeal,  sensory  to  the  tongue  and  pharynx. 

10.  Vagus  or  Pneumo-gastric  nerve,  has  an  extensive 
motor  and  sensory  distribution.  It  is  involved  in  lesions  of  the 
base  of  the  brain,  or  medulla,  and  causes  serious  or  fatal  dis- 
turbance in  respiration  or  circulation.  Special  branches  may 
be  injured  in  surgical  operations  about  the  neck. 

11.  Spinal  accessory,  motor  to  the  trapezius  and  muscles 
of  the  neck,  is  most  often  injured  or  cut  accidentally  in  the 
removal  of  enlarged  cervical  lymph-nodes,  and  results  in  ina- 
bility to  raise  the  shoulder. 

12.  Hypoglossal  nerve,  motor  to  the  muscles  of  the 
tongue. 

Peripheral  spinal  nerves  are  given  off  in  pairs,  and  leave 
the  vertebral  canal  between  the  bodies  of  the  vertebrae.  Each 
nerve  is  mixed,  i.e.,  contains  motor  and  sensory  fibres.  In 
certain  regions  several  segmental  nerves  form  a  "plexus" 
where  the  fibres  are  intermingled  and  rearranged  in  special 
nerve  trunks.    (See  Anatomy  of  the  Brachial  Plexus,  Fig.  28.) 

Lesions  of  a  nerve  proximal  to  a  plexus  cause  more  diffuse 
effects  than  those  of  a  special  trunk,  i.e.,  there  will  result  a 
"paresis"  (weakening)  of  a  group  of  muscles  instead  of  par- 
alysis of  a  smaller  number,  and  the  sensory  disturbance  will 
be  less  definite  and  cover  a  greater  area.  By  means  of  special 
studies  of  the  area  concerned  it  is  possible  to  determine  the 
nerves  which  are  involved,  and  the  location  of  the  lesion. 
Complete  separation  of  a  nerve  fibre  or  destruction  of  its  motor 
cells  in  thje  cord  is  characterized  by  the  typical  "reaction  of 
degeneration"   in   the  muscles  concerned.    In  this   case  it  is 


114       ESSENTIALS  OF  SURGERY  FOR  NURSES 

assumed  that  recovery  is  impossible,  and  the  only  hope  of 
relief  lies  in  the  possibility  of  re-establishing  the  continuity  of 
the  peripheral  nerve  by  surgical  operation. 

Lesser  degrees  of  disturbance  where  the  continuity  of  the 
nerve  fibres  is  not  broken,  resulting  from  torsion,  disease,  ex- 
posure to  cold,  or  toxsemias,  offer  a  better  prognosis,  after  rest, 
massage,  and  electrical  stimulation. 

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5C,  6C,  7C,  8C,  and  \T,  lower  cervical  and  upper  thoracio 
spinal  nerves. 


DEMONSTRATIONS 

1.  Case  or  specimen  of  an  aneurism  of  peripheral  artery,  popliteal. 

2.  Apparatus  and  solutions  for  transfusion  of  blood. 

3.  Demonstration  and  practice  in  applying  pressure  bandage  for  varicose 

veins. 

4.  Demonstration  of  padded  bandage  and  protection  for  phlebitis. 


NERVOUS  SYSTEM  115 

5.  Demonstration  of  cases  or  histories  showing  involvement  of  lymph- 

nodes;  (a)  with  resolution  following  incision  and  drainage  of  primary- 
focus;  (6)  with  suppuration  of  lymph-nodes. 

6.  Tuberculous  involvement  of  lymph-nodes. 

7.  If  possible,  demonstration  and  explanation  of  effects  of  (a)  "upper 

segment"  paralysis  (apoplexy),  (5)  "lower  segment"  paralysis  lesion 
of  cranial  or  peripheral  nerve. 

8.  Demonstration  of  apparatus  and  method  of  "lumbar  puncture." 

9.  Study  of  case  or  history  of  concussion  of  brain  with  recovery. 

10.  Case  or  case  history  of  traumatic  intracranial  hemorrhage. 

11.  Same  of  brain  abscess  or  septic  meningitis  following  injury  or  operation. 

12.  Demonstration  of  case  with  complications  of  serious  injury  to  the 

vertebral  column  and  cord. 


CHAPTER  Vm 
THE  HEAD— CRANIUM  AND  FACE. 

The  Cranium  includes  the  portion  of  the  skull  which  en- 
closes the  brain.  The  vault  is  composed  of  the  squamous  or 
flat  portions  of  the  frontal,  occipital,  and  parietal  bones.  The 
base  is  formed  by  the  orbital  plate  of  the  frontal,  the  body 
and  wings  of  the  sphenoid,  the  petrous  part  of  the  temporal, 
and  the  basilar  part  of  the  occipital  bones. 

The  coverings  of  the  cranium  are:  (1)  The-  scalp,  composed 
of  thick  skin,  rich  in  hair  follicles  and  sebaceous  glands,  with 
its  vascular  dense  fatty  layer.  (2)  A  fibrous  layer  composed  of 
the  aponeurosis  of  the  fronto-occipitalis  muscle,  attached  in 
front  to  the  supraorbital  ridge,  laterally  to  the  temporal  fascia, 
and  posteriorly  to  the  occipital  bone.  (3)  The  periosteal  layer 
of  the  cranial  bones  is  attached  firmly  along  the  suture  lines, 
hence  collections  of  blood  or  pus  are  definitely  limited. 

Surgical  lesions  of  the  scalp  include :  (A)  Wounds,  (B)  Infec- 
tions, and  (C)  Tumors. 

A.  Open  wounds  are  usually  of  the  "incised"  type,  even 
those  resulting  from  blows  or  injury  with  a  blunt  instrument. 
The  edges  of  the  wound  gape,  especially  if  the  aponeurotic 
layer  is  involved. 

(1)  Hemorrhage  is  always  free,  since  the  blood-supply  is 
rich,  though  rarely  becomes  serious  and  is  easily  controlled  by 
pressure  bandage  or  suture  of  the  wound.  (2)  Infection  is 
common  in  an  accidental  wound  of  the  scalp,  though  it  seldom 
makes  much  progress  if  properly  cared  for.  In  some  cases 
where  the  wound  has  been  closed  tightly,  with  inadequate 
provision  for  drainage,  extensive  infection  and  sepsis  may 
develop.  When  the  sub-aponeurotic  layer  is  involved,  purulent 
material  collects  under  the  fascia,  being  limited  only  by  the 
attachments  of  the  fronto-occipitalis  muscle.  Adequate  drain- 
age is  difficult  to  secure,  and  heafing  is  slow.  Extension  by 
means  of  perforating  lymphatics  or  veins  through  the  skull 
may  result  in  periostitis,  meningitis,  or  brain  abscess. 

116 


THE  HEAD— CRANIUM  AND  FACE  117 

(3)  Injury  to  the  skull  or  brain  may  occur,  complicating 
any  scalp-wound  due  to  violence,  and  must  be  definitely  ex- 
cluded before  the  case  is  dismissed  from  surgical  care. 

First  Aid. — The  hair  surrounding  the  wound  is  shaved  or 
clipped,  the  area  cleansed  by  antiseptic  irrigation  or  swab- 
bing with  tincture  of  iodine,  pockets  explored  and  foreign  ma- 
terial removed.  Interrupted  sutures  are  commonly  used  to 
allow  drainage  and  to  prevent  undue  tension  in  case  of  infection. 
Wet  antiseptic  dressings  may  be  indicated. 

B.  Infections  of  the  scalp  may  comphcate  wounds,  or  arise 
spontaneously  as  mild  abscesses  or  furuncles.  The  rich  blood- 
supply  offers  strong  resistance,  and  prompt  healing  is  the  rule 
if  there  is  adequate  drainage.  Infections  are  usually  well  local- 
ized and  extension  is  limited  by  the  dense  fibrous  structures  of 
the  subcutaneous  tissue,  except  where  the  process  has  extended 
under  the  aponeurosis.  Infections  of  the  bone  under  the  peri- 
osteum are  limited  by  the  attachment  of  the  periosteum  along 
the  sutures.      The  complications  have  already  been  discussed. 

Carbuncle  represents  a  chronic  type  of  infection,  usually 
located  at  the  back  of  the  neck  near  the  hair  line,  and  charac- 
terized by  a  progressive  destruction  of  tissue,  and  sluggish  but 
continuous  extension.  It  is  associated  with  and  caused  hy 
constitutional  disease:  Diabetes,  advanced  nephritis,  and  low 
general  resistance.  The  prognosis  is  grave,  in  most  cases, 
as  the  process  seems  to  extend  in  spite  of  usual  local  treatment. 

C.  Tumors  of  the  scalp  include  some  which  are  congenital 
or  present  at  birth.  "Meningocele,"  a  rare  congenital  condition 
due  to  protrusion  of  the  meninges,  dura,  and  arachnoid  between 
the  sutures  of  the  cranial  bones.  Such  a  sac  contains  cerebro- 
spinal fluid  and  communicates  directly  with  the  cerebro- 
spinal space,  and  becomes  tense  when  the  child  cries  or  strains. 
The  tumor  is  characterized  by  the  fact  that  compression  raises 
the  intracranial  pressure  and  causes  unconsciousness.  There 
are  often  other  congenital  defects.  Spontaneous  cure  is  rare, 
and  surgical  measures  are  usually  necessary,  but  meningitis  is  a 
frequent  compHcation.  Recurrence  is  not  uncommon.  Other 
tumors  of  the  scalp  are  usually  of  slight  consequence.  They 
include  sebaceous  cysts,  "wens,"  and  are  often  multiple.  Such 
tumors  may  reach  considerable  size,  and  recur  unless  all  of  the 
secreting  epithelium  lining  of  the  cyst  is  removed.     Infection 


118       ESSENTIALS  OF  SURGERY  FOR  NURSES 

may  occur  from  the  surface,  due  to  irritation.  Surgical  removal 
can  usually  be  done  under  local  anaesthesia. 

Injuries  to  the  scalp  and  skull  may  occur  at  birth  from 
forceps  delivery,  or  from  pressure  during  slow,  difficult  deliv- 
ery. (1)  Lacerations  or  bruises  of  the  scalp  heal  kindly  with 
compresses  of  boracic  acid  solution.  (2)  Localized  collection  of 
blood  or  fluid  under  the  scalp,  due  to  pressure,  is  usually  ab- 
sorbed spontaneously  and  is  of  slight  consequence.  (3)  Injury  to 
the  skull  with  depression  of  the  bone  causes  serious  lesions  of 
the  underlying  brain,  or  extensive  intracranial  hemorrhage. 
This  may  result  in  death  within  a  few  hours  or  days,  or  leave 
permanent  defects.  In  certain  cases  early  decompression 
operation,  elevation  of  the  depressed  bone  and  evacuation  of 
clots,  is  indicated  and  gives  marked  results. 

Fracture  of  the  vault  or  of  the  base  of  the  skull  represent 
the  chief  surgical  lesion  of  the  bony  cranium  and  results  from 
direct  violence,  blows  to  the  head,  or  falling  and  striking  the 
head  against  a  solid  obj  ect.  Two  tj^pes  of  fracture  are  described. 
(1)  Depressed  fracture,  causing  laceration  and  local  pressure 
on  the  brain  with  marked  disturbance.  (2)  Linear  fracture 
with  no  displacement  of  bone  or  external  evidence  of  injury, 
though  there  may  be  extensive  intracranial  hemorrhage. 

1.  Fractures  of  the  vault  of  the  skull  occur  at  the  site  of 
violence  but  have  a  tendency  to  extend,  especially  to  the  base, 
as  linear  fractures. 

2.  Fractures  of  the  base  occur  as  independent  lesions  from 
violence,  or  more  often  as  an  extension  of  a  fracture  of  the  vault. 
These  are  more  serious  because  of  the  relations  of  the  vital 
centres  in  the  medulla  which  are  directly  exposed  to  pressure. 
The  prognosis  is  exceedingly  grave.  Many  patients  never 
regain  consciousness. 

Effects  of  fracture  are  (1)  local,  and  (2)  general. 

1.  Local  effects  may  be  due  to:  (a)  Depressed  fragments  of 
bone  and  laceration  of  brain  substance,  (h)  Intracranial  hem- 
orrhage due  to  injury  to  the  meningeal  vessels.  These  effects 
will  depend  upon  the  area  of  the  brain  which  is  involved  (see 
page  106),  i.e.,  injury  or  pressure  affecting  the  motor  area 
causes  paralysis  of  the  opposite  side  of  the  body.  Injury  to  the 
base  affects  the  circulatory  or  respiratory  centres  in  the  me- 
dulla and  is  often  fatal.    The  special  local  effects  may  be  ob- 


THE  HEAD— CRANIUM  AND  FACE  119 

scured  by  the  general  condition.  Late  local  changes  due  to 
thickening  from  callus  formation  may  cause  irritation  of  the 
cortex,  with  spasmodic  convulsive  attacks  or  ''Jacksonian" 
epilepsy  (see  page  106) .  New-growths  hav  e  been  described  as  de- 
veloping at  the  site  of  a  previous  fracture  of  the  skull,  though 
it  cannot  be  claimed  to  be  a  cause. 

2.  General  effects  are  due  to  disturbance  of  intracranial 
tension  resulting  from  depressed  bone,  or  hemorrhage.  There 
is  usually  unconsciousness  following  the  injury  which  may 
persist  until  death  ensues,  especially  in  the  more  serious  fract- 
ures, especially  those  of  the  base.  In  other  instances  after  a 
variable  period,  minutes  or  hours,  this  clears  with  persisting 
evidence  of  increased  pressure:  stupor,  headache,  vomiting, 
slow  pulse,  high  blood-pressure,  and  a  characteristic  mental 
condition  of  irritability,  which  sometimes  amounts  to  child- 
ishness. When  the  disturbance  is  mild,  these  symptoms  grad- 
ually clear,  leaving  no  permanent  effect.  In  case  of  serious 
hemorrhage,  there  is  likely  to  be  a  clear  period  of  consciousness 
following  the  initial  unconsciousness  which  was  due  to  concus- 
sion, after  which  there  is  a  gradual  development  of  evidence  of 
increasing  intracranial  pressure,  which  may  be  progressively 
fatal. 

Indications  for  Treatment, — Careful  observation  of  all 
head  injuries  to  avoid  overlooking  fracture  or  intracranial 
hemorrhage.  Evidence  of  a  depressed  fracture  is  indication 
for  surgical  treatment :  elevation  of  the  fragment,  and  relief  of 
pressure.  The  operation  requires  the  most  rigid  aseptic  tech- 
nique and  should  be  followed  by  marked  improvement.  Lin- 
ear fracture  and  intracranial  hemorrhage  is  recognized  by 
evidence  of  local  lesion  of  the  cerebral  cortex,  or  increased 
intracranial  pressure,  and  calls  for  prompt  surgical  treatment, 
craniotomy  and  control  of  hemorrhage. 

Infections  of  the  skull,  aside  from  those  associated  with 
injury,  involve  the  same  local  changes  and  principles  of  treat- 
ment as  periostitis.  The  most  serious  special  consideration  is 
the  danger  of  extension  by  means  of  communicating  lymph  or 
blood-vessels,  resulting  in  meningitis  or  brain  abscess. 

Tumors. — Exostoses  protruding,  from  the  surface  of  the 
skull  are  hard,  non-malignant  growths  and  are  easily  removed, 
without  recurrence.     New-growths  involving  the    interior    of 


120      ESSENTIALS  OF  SURGERY  FOR  NURSES 


the  skull  have  already  been  considered  in  connection  with  the 
brain  and  meninges.     (See  page  112.) 

THE  EAR  AND  MASTOID  PROCESS  OF  THE  TEMPORAL  BONE 

A.  The  external  ear  (Fig.  29)  is  composed  of  cartilage 
covered  with  a  small  amount  of  areolar  tissue  and  skin.  Wounds 
involving  the  cartilage  heal  slowly  since  there  is  poor  blood 
supply.  Frost-bites  are  common  but  usually  involve  only  the 
skin.  The  subsequent  swelling  and  congestion  is  extremely 
painful.     In  case  the  cartilaginous  portion  is  frozen,  (there  may 


T£MPORAL 


T£MPO/PAL 

bone: 

CAfiT/LAGE. 
OF  CANAL 

CONC//A 


£X.  Atrorropy 

CANAL 


MALLEUS  OF  TY/^PANUM 
■  GEN/C(/LAT£  GA/Va 


FAC/AL  M 


AUDA8(N. 


/NT.  £AP 

POSTL/MB  OF 
5i/P  5£L^/C//?C  CAMAL 

T/MPAN/C  M£/^£PAN£ 


Fig.  29. 


MASrO/D  ANTRl/M 

-External  ear  and  canal. 


be  a  loss  of  tissue.  Injury  from  blows  often  results  in  the  accu- 
mulation of  a  considerable  hsematoma  under  the  perichondrium 
with  permanent  deformity. 

The  external  auditory  canal  extends  from  the  surface  to  the 
"tympanum"  or  "drum  membrane"  of  the  middle  ear.  The 
canal  is  lined  with  cutaneous  epithelium  and  has  a  peculiar 
secretion,  "wax"  or  cerumen. 

Lesions  include:  (1)  infection;  (2)  foreign  bodies;  (3) 
collections  of  wax. 

1.  Infection  is  usually  a  "furuncle"  or  skin  abscess,  and 
is  very  painful.  It  presents  the  same  symptoms  and  indication 
for  treatment  as  does  an  abscess  elsewhere. 

2.  Foreign  bodies  lodged  in  the  canal  cause  pain,  swelling, 
and  interfere  with  hearing.     Removal  is  often  difficult.     The 


THE  HEAD— CRANIUM  AND  FACE 


121 


use  of  probes  or  forceps  is  not  permissible  except  in  the  hands  of 
experts,  on  account  of  the  danger  of  injury  to  the  canal  or  drum 
membrane.  The  use  of  a  syringe  and  water  is  successful  in 
removing  foreign  matter,  except  seeds  or  vegetable  materials 
which  swell,  in  which  case  oil  may  be  used. 

3.  Collections  of  cerumen  may  accumulate  in  the  canal, 
forming  hard  masses,  causing  ringing  in  the  ears,  or  deafness. 
Removal  is  usually  accomplished  by  syringing  the  ear  with  a 
strong  piston  syringe. 


MASTO/O 
CAV/TY 


TENSOR 
TYMPAA// 


^L/STAC/y/A/V      ,^ 

TUBE  <^  TYMPA/V/C 

MEMB/?A/VE 

Fig.  30. — Middle  ear,  Eustachian  tube,  and  mastoid  cells. 

B.  The  middle  ear  (Fig.  30)  is  separated  from  the  external 
canal  by  the  tympanum,  and  contains  the  "ossicles,"  malleus, 
stapes  and  incus,  which  transmit  the  sound-waves  from  the 
drum  membrane  to  the  inner  ear,  and  special  endings  of  the 
auditory  nerve.  It  is  adjacent  to  the  air  cells  of  the  mastoid 
process  of  the  temporal  bone.  It  communicates  with  the  phar- 
ynx through  the  Eustachian  canal,  by  means  of  which  infection 
may  reach  the  middle  ear.  This  communication  explains  the 
frequent  sequence  of  acute  middle-ear  disease  foHowing  infec- 
tious processes  in  the  throat  and  tonsils. 

Surgical  lesions  include  various  forms  of  infectious  proc- 
esses with  their  extensions  to  the  mastoid  cells.     These  are 


122      ESSENTIALS  OF  SURGERY  FOR  NURSES 

secondary  to  inflammation  of  the  naso-pharynx  and  adenoids 
from  tonsillitis,  measles,  scarlet  fever,  and  milder  or  more  ob- 
scure conditions,  usually  extending  along  the  Eustachian  tube. 
Two  types  of  Inflammation  of  the  middle  ear  are  described: 

1.  Catarrhal,  associated  with  mild  inflammation  and  accu- 
mulation of  serous  exudate,  but  no  suppuration.  There  is  severe 
pain,  "earache,"  usually  fever,  and  constitutional  reaction. 
Examination  of  the  tjonpanum  with  a  speculum  shows:  Injec- 
tion, bulging,  and  evidence  of  fluid  in  the  tympanic  cavity. 
Outcome:  (a)  Favorable,  spontaneous  recovery  with  absorption 
of  fluid  and  restoration  of  normal  drainage  through  the  Eus- 
tachian canal,  with  no  after-effects.  Indications  for  treatment: 
Heat  locally,  irrigations  of  hot  boric  acid  or  normal  salt  solu- 
tion, or  injection  of  2%  phenol  in  glycerin  into  the  external 
auditory  canal.  (6)  Progressive  inflammation  with  suppuration. 

2.  Suppurative  Form. — This  represents  an  advanced  stage  of 
the  catarrhal  type  which  may  have  been  of  short  duration  and 
entirely  overlooked.  There  is :  Destruction  of  tissue,  increased 
tension  in  the  middle  ear,  more  pain,  fever,  and  constitutional 
reaction.  Examination  of  the  tjrmpanum  demonstrates :  Bulg- 
ing of  the  drum,  presence  of  fluid  in  the  middle  ear,  and  often 
necrosis  or  rupture  of  the  tympanum.  Rupture  of  the  drum 
membrane  may  occur  at  any  stage  of  the  disease,  being  followed 
by  relief  of  sjmaptoms,  and  a  purulent  discharge  from  the  ear. 
It  is  often  the  first  evidence  of  the  location  of  obscure  sepsis. 
Surgical  incision  of  the  tympanum  is  preferable  to  spontaneous 
rupture  because:  (a)  It  prevents  unnecessary  destruction  of 
tissue,  relieves  pain  and  toxgemia.  (6)  It  aUows  better  drainage, 
since  it  can  be  made  in  the  most  advantageous  position,  (c) 
There  is  less  danger  of  premature  closure  and  recurrence. 

The  Outcome  of  the  middle-ear  suppuration  may  be:  (a) 
Favorable.  Drainage  persists  for  some  weeks  till  the  cavity  is 
clear,  in  which  case  recovery  is  complete  and  permanent  with 
but  little  impairment  of  hearing.  (6)  Unfavorable,  (i)  Ex- 
tensive destruction  of  tissues  in  the  middle  ear,  with  permanent 
impairment  of  hearing,  (ii)  Premature  closure  of  the  opening 
in  the  drum  membrane,  leaving  septic  and  necrotic  material 
in  the  cavity,  in  which  case  recurrence  is  not  uncommon  months 
or  years  later,  resulting  in  a  chronic  discharging  ear.  (iii)  Ex- 
tension of  the  infection  to  the  cancellous  portion  of  the  temporal 


THE  HEAD— CRANIUM  AND  FACE  123 

bone,  particularly  the  mastoid  process.  This  is  a  frequent  se- 
quel and  is  evident  by  persistence  or  recurrence  of  constitutional 
symptoms:  Fever,  toxaemia,  local  pain,  and  tenderness  over 
the  mastoid.  In  young  children  suppuration  may  extend  to  the 
subcutaneous  tissue,  and  there  will  then  be  superficial  signs  of 
suppuration. 

Complications  in  neglected  cases:  (1)  Extension  to  the 
venous  sinuses  of  the  brain  with  septic  thrombi  which  may  also 
involve  the  Jugular  vein  in  the  neck.  (2)  Brain  abscess  which 
involves  the  portion  adjacent  to  the  petrous  part  of  the  tempo- 
ral bone.  (3)  Chronic  suppuration,  and  persistent  discharge, 
with  deafness. 

Principle  of  Treatment — Definite  evidence  of  involvement  of 
the  mastoid  cells  is  indication  for  the  "radical  mastoid  opera- 
tion," exposure  of  the  suppurating  area,  excision  of  necrotic 
tissue,  and  drainage  to  allow  complete  healing, 

DEMONSTRATIONS 

1.  Case  histories  showing  compUcations  of  scalp  wounds;  fracture  of  skull, 

sepsis,  or  brain  abscess. 

2.  Case  history  of  carbuncle  or  exhibition  of  suitable  case. 

3.  Injuries  to  scalp  and  skull  from  difficult  labor. 

4.  Case  history  of  fracture  of  skull  or  exhibition  of  museum  specimen. 

5.  Demonstration  of  external  auditory  canal  and  tympanic  membrane. 

6.  Method  of  syringing  the  external  ear  for  foreign  body,  or  discharging 

ear. 

7.  History  of  typical  case  of  middle-ear  suppuration  with  extension  to 

mastoid,  showing  result  of  perforation  of  drum,  and  radical  operation. 

THE  FACE 

This  region  includes  the  lower  part  of  the  head  and  skull: 
Forehead,  eye  and  orbit,  cheek,  nose  and  sinuses,  mouth,  Ups, 
and  throat  (pharynx.) 

The  Forehead  represents  the  region  of  the  frontal  bone. 
The  skin  and  subcutaneous  tissues  are  highly  vascular.  Wounds 
bleed  freely,  but  ligation  of  vessels  is  rarely  required,  careful 
suture  usually  being  sufiicient  to  control  hemorrhage,  and  is 
necessary  to  prevent  unsightly  scar.  Infections  are  usually 
local  and  have  no  peculiar  significance,  differing  from  those  of 
the  scalp. 

Eyes. — It  is  possible  only  to  mention  some  of  the  more  im- 
portant surgicallesions,  including:  (A)  Injury;  (B)  Infections; 
(C)  Tumors. 


124      ESSENTIALS  OF  SURGERY  FOR  NURSES 

A.  Injury:  (1)  Small  foreign  bodies,  cinders  or  dust,  cause 
pain  from  irritation  of  the  conjunctiva,  and  if  neglected  result 
in  infection,  conjunctivitis,  or  ulcers  of  the  cornea. 

Principles  of  treatment:  (a)  Removal  of  the  foreign  body 
by  reflection  of  the  lids  requires  skilful  and  gentle  manipulation. 
(6)  Irrigation  with  bland  antiseptic  lotion,  saturated  boracic 
acid  solution,  (c)  Temporary  compress  and  tight  bandaging 
when  removal  is  impossible. 

2.  Penetrating  wounds  of  the  eyeball  usually  cause  destruc- 
tion of  tissue  and  loss  of  function  from  ulceration  of  the  cornea, 
leaving  opaque  areas  which  shut  out  the  light  rays.  There  may 
also  be  (a)  injury  to  the  lens  and  development  of  cataract, 
(h)  injury  to  the  retina  or  optic  nerve.  Infection  of  the  damaged 
eye  is  common  and  there  is  serious  danger  of  extension  to  the 
uninjured  eye,  or  "sympathetic  ophthalmia."  This  possibility 
is  usually  sufficient  indication  for  the  surgical  removal  of  an 
eyeball  which  is  damaged  to  a  degree  resulting  in  total  loss  of 
function. 

Blindness  may  be  caused  by:  (a)  Injury  from  foreign  body, 
or  infection,  conjunctivitis  (gonorrheal)  involving  the  cornea, 
resulting  in  opaque  scar  tissue  which  prevents  the  passage  of 
light  rays,  (b)  "Cataract,"  degeneration  and  opacity  of  the 
lens  from  any  cause.  The  lens,  however,  may  be  removed  surgi- 
cally, leaving  no  obstruction  to  the  light  rays,  but  the  power  of 
accommodation  is  lost  and  must  be  compensated  for  by  spe- 
cial glasses,  (c)  Destruction  of  the  eyeball,  (d)  Lesions  of  he 
retina,  optic  nerve,  or  brain  centre. 

B.  Surgical  infections  are  practically  limited  to  those 
associated  with  injury,  or  due  to  suppurating  (gonorrheal) 
conjunctivitis.     (See  page  33.) 

C.  Tumors. — The  most  important  is  a  type  of  the  melano- 
sarcoma  which  develops  in  the  pigment  layer  of  the  choroid. 
There  are  few  early  symptoms  aside  from  progressive  impair- 
ment of  vision,  and  the  diagnosis  is  made  by  an  ophthalmo- 
scopic examination  of  the  retina.  The  tumor  is  rapidly  malig- 
nant and  metastases  develop  early  in  remote  parts  of  the 
body.  Prompt  enucleation  of  the  eyeball  is  indicated,  but  the 
prognosis  is  always  unfavorable. 

It  should  be  emphasized  that  disturbances  in  vision  call  for 
examination  by  a  competent  ophthalmologist,  since  the  trouble 


THE  HEAD— CRANIUM  AND  FACE 


125 


may  be  evidence  of  serious  local  or  constitutional  disease: 
Cataract,  tumor,  increased  intracranial  tension  (brain  tumor), 
nephritis,  and  certain  toxaemias,  for  instance,  wood  alcohol, 
tobacco,  etc.  While  the  commercial  optician  may  correct  a 
simple  error  of  refraction  with  suitable  glasses,  he  is  not  pre- 
pared to  exclude  other  causes.  This  distinction  must  be  care- 
fully explained  to  patients  in  order  that  they  may  seek  and 
obtain  competent  advice. 


LEV.  PALf>  SUP 
SC/P  OBL/QUE 
SUP 
EXT  PECTUS 
/A/TPEOT/S 


TPOCPLE/f 


EXT  PECTUS 


/A/E  OBL/QUE 


/A/E  PECTUS 
OPT/C  A/EPI/E 

Fig.  31. — The  orbit  and  contents. 


The  Orbit  (Fig.  31)  is  the  bony  wall  which  surrounds  the 
eyeball,  composed  of:  The  orbital  plate  of  the  frontal  bone, 
parts  of  the  ethmoid,  sphenoid,  superior  maxillary,  and  malar 
bones.  It  contains  the  eyeball  with  its  extrinsic  muscles,  nerves, 
and  blood-vessels,  together  with  a  large  amount  of  fat. 

A.  Injuries  are  caused  by  penetrating  wounds  which  may  or 
may  not  involve  the  eyeball.  Foreign  bodies  of  considerable 
size  can  enter  the  orbit  without  injury  to  the  eyeball  and 
leave  no  external  evidence. 

Dangers:  (a)  Injury  to  the  eyeball.  (b)  Conjunctivitis, 
(c)  Penetration  of  the  orbital  plate  and  injury  to  the  brain, 


126      ESSENTIALS  OF  SURGERY  FOR  NURSES 

or  septic  meningitis,  (d)  Laceration  of  vessels  and  develop- 
ment of  a  hgematoma  or  aneurism,  (e)  Extensive  suppuration 
in  the  loose  fat  of  the  orbit,  which  is  common  and  serious  since 
it  may  be  followed  by  meningitis  or  brain  abscess,  either  through 
direct  extension  or  communicating  vessels,  and  lymphatics. 

B.  Tumors  of  the  orbit  include:  (a)  Vascular  aneurisms. 
(b)  Connective  tissue  tumors  or  extensions  from  growths  in 
the  maxillary  antrum.  Evidence  of  tumor  or  collection  in  the 
orbit  is  a  unilateral  "exophthalmos,"  i.e.,  prominent  bulging 
of  the  eyeball.  Surgical  removal  of  such  tumors  is  difficult  and 
recurrence  is  not  infrequent 

The  CHEEK  is  limited  above  by  the  malar  bone  and  zygo- 
matic arch,  and  below,  by  the  angle  of  the  lower  jaw.  There  is 
for  consideration:  The  skin  and  subcutaneous  fat,  the  muscles 
of  -  expression,  the  facial  nerve  and  vessels,  the  trifacial  nerve, 
the  parotid  gland  and  duct  (Stenson's). 

The  SKEST  AND  SUBCUTANEOUS  FAT  are  soft  and  vascular. 

1.  Wounds  bleed  profusely  and  branches  of  the  facial  artery 
may  require  ligation.  Injury  to  the  parotid  (Stenson's)  duct 
may  be  followed  by  a  persistent  salivary  fistula,  and  demand  a 
special  plastic  operation  to  secure  closure.  Penetrating  wounds 
to  the  mouth  are  rare.  Injury  to  branches  of  the  facial  nerve  or 
muscles  of  expression  is  followed  by  permanent  paralysis. 
Careful  suture,  accurate  apposition  with  asepsis  are  necessary  to 
avoid  scars. 

2.  Infections,  (a)  Erysipelas,  already  considered  under 
streptococcus  infections  (see  page  32),  often  occurs,  apparently 
spontaneously,  in  the  skin  over  the  bridge  of  the  nose  and  ex- 
tends to  one  or  both  cheeks.  There  is  local  pain,  swelling,  and 
redness,  with  constitutional  evidence  of  severe  infection.  (6) 
Superficial  abscesses  occur  as  in  other  regions,  there  being 
little  of  particular  significance.  Prompt  incision  is  indicated  as 
soon  as  there  is  evidence  of  suppuration,  to  avoid  tissue  de- 
struction and  unsightly  scar,  (c)  Deep  abscesses  may  reach 
considerable  extent  in  the  abundant  subcutaneous  fat.  They 
may  originate  from:  the  parotid  gland,  lymph-nodes,  root 
abscesses  from  carious  teeth,  and  less  often  from  osteomyelitis 
of  the  upper  or  lower  jaw.  There  is  marked  pain,  swelling,  and 
constitutional  effect.  Surgical  incision  is  indicated  as  soon  as 
suppuration  can  be  demonstrated.     Care  is  necessary  to  avoid 


THE  HEAD— CRANIUM  AND  FACE  127 

injury  to  the  facial  vessels  or  nerves,  to  the  parotid  duct, 
penetration  to  the  mouth,  or  excessive  scar.  Healing  is  usually 
rapid  and  complete. 

The  MUSCLES  OF  EXPRESSION  iucludo  the  voluntary  muscles 
attached  to  the  skin  and  subcutaneous  fat  and  controlling  the 
movements  of  facial  expression.  They  are  supplied  by  the  VII 
cranial  or  facial  nerve.  Paralysis  of  these  muscles  is  caused  by: 
Disturbance  of  the  cerebral  centre  or  central  tracts  between 
this  and  the  nuclei  of  origin  of  the  nerve  in  the  medulla,  injury 
or  lesion  of  the  nerve  in  the  middle  ear,  or  of  the  nerve  after 
leaving  the  skull.  The  paralysis  involves  the  facial  muscles, 
resulting  in  a  peculiar  wooden  expression  and  lack  of  mobility 
of  the  features.  Outcome:  Unless  the  centre  is  destroyed  or  the 
nerve  severed,  which  is  rare  except  following  operations  on  the 
middle  ear  and  mastoid,  there  is  more  or  less  complete  recovery; 
otherwise  the  condition  is  permanent. 

In  some  instances  where  the  peripheral  nerve  is  severed, 
resulting  in  complete  and  permanent  paralysis,  it  has|been 
possible,  by  surgical  measures,  to  make  an  anastomosis  be- 
tween the  peripheral  end  of  the  facial  and  the  central  end  of 
that  nerve,  or  of  another  motor  nerve,  giving  complete  regen- 
eration. Injury  to  branches  of  the  nerve  in  wounds  of_the  face 
cause  paralysis  of  the  dependent  muscles. 

The  Trifacial  Nerve  (see  page  112). — The  most  impor- 
tant lesion  is  trifacial  neuralgia,  characterized  by  severe  par- 
oxysmal pain,  associated  with  muscular  twitching  and  points  of 
extreme  tenderness  where  the  three  principal  branches  of  the 
nerve  leave  the  skull:  (1)  Supraorbital  foramen,  through  which 
the  terminal  branch  of  the  first  division  of  the  nerves  passes. 
(2)  The  infraorbital  foramen  and  the  terminal  branch  of  the 
second  division.  (3)  The  mental  foramen  in  the  lower  jaw, 
through  which  the  terminal  branch  of  the  inferior  maxillary, 
third  division  of  the  nerve,  passes.  The  cause  are  not  known, 
but  include:  irritations  of  nerve  endings  by  root-abscesses  or 
remote  lesions,  and  constitutional  conditions  not  explained. 
The  course  is  variable,  the  attacks  being  influenced  but  little 
by  local  or  constitutional  treatment,  except  measures  which 
destroy  the  nerve. 

Principles  of  Treatment. — Relief  of  pain  is  the  most  urgent 
indication.    For  mild  attacks,  heat  locally  or  lotions  and  appli- 


128      ESSENTIALS  OF  SURGERY  FOR  NURSES 

cations  of  counter-irritants,  such  as  chloroform  liniment  or 
menthol,  may  be  of  value.  Hypnotic  drugs  must  be  used  with 
care  since  they  soon  lose  their  efficiency  and  large  doses  may  be 
taken.  For  severe  paroxysms  nothing  avails  short  of  morphine 
in  considerable  dosage.  There  is  great  danger  of  developing  the 
habit  and  the  drug  is  to  be  used  only  on  the  direct  order  of  the 
physician  for  each  dose.  In  cases  where  the  attacks  persist  or 
recur,  more  radical  measures  are  indicated.  Unless  relief  is 
given  the  persistent  pain  and  loss  of  sleep  may  give  rise  to  the 
morphine  habit,  or  even  drive  the  patient  to  suicide. 
Curative  measures  include: 

(1)  Injection  of  the  peripheral  branches  through  the  cor- 
responding foramen  with  a  destructive  agent  (osmic  acid) 
to  destroy  the  branch.  The  results  are  uncertain  and  only 
temporary. 

(2)  Injection  of  alcohol  into  the  principal  roots  or  into  the 
Gasserian  ganghon  through  the  "foramen  ovale"  at  the  base  of 
the  skull.  In  the  hands  of  experts  this  foramen  can  be  reached, 
by  means  of  a  suitable  needle,  from  the  surface  of  the  face. 
While  the  technique  of  the  procedure  is  difficult  and  there  is 
some  danger  of  serious  complications,  the  results  are  often 
remarkable  and  permanent. 

(3)  Exposure  of  the  Gasserian  ganglion  by  surgical  crani- 
otomy followed  by  division  of  the  sensory  branches  or  total  ex- 
cision of  the  ganglion  of  origin  of  the  sensory  fibres.  This  pro- 
cedure is  reserved  for  the  most  severe  and  persistent  cases, 
and  is  an  extremely  serious  operation,  but  the  results  are  usually 
absolute  and  permanent. 

The  Blood-vessels. — The  temporal  artery,  a  termmal 
branch  of  the  external  carotid,  with  the  temporal  veins,  passes 
just  in  front  of  the  external  ear  behind  the  angle  of  the  jaw, 
where  it  is  protected  from  accident.  The  facial  artery,  also 
a  branch  of  the  external  carotid,  reaches  the  face  over  the 
middle  of  the  lower  jaw,  where  it  can  be  palpated.  Both  vessels 
give  off  branches  of  considerable  size  to  the  face,  mouth,  throat, 
and  nose,  and  require  ligation  when  concerned  in  hemorrhage. 

The  Parotid  gland,  one  of  the  principal  salivary  glands,  is 
located  in  the  cheek  above  the  angle  of  the  jaw,  in  front  of  the 
ear.  Passing  through  the  gland  are  found  branches  of  the  facial 
nerve  and  of  the  external  carotid  artery. 


THE  HEAD— CRANIUM  AND  FACE  129 

Lesions:  (1)  Acute  parotitis,  "mumps,"  is  an  epidemic 
infection  which  involves  this  gland  primarily,  the  causal  organ- 
ism of  which  is  not  known.  There  is  marked  local  pain  and 
swelling,  but  suppuration  is  rare.  Complications  may  be  serious, 
but  the  condition  is  not  surgical.  (2)  Suppuration  of  the  parotid 
gland  is  an  occasional  complication  of  (a)  severe  constitutional 
infections  associated  with  low  resistance,  and  (6)  post-operative 
convalescence,  probably  from  sepsis  about  the  mouth,  and 
low  resistance.  The  complication  is  evidence  of  extremely 
poor  resistance  and  gives  a  grave  prognosis.  Early  incision  is 
indicated. 

(3)  Tumors  of  the  parotid  are  not  common.  Fibromas  and 
mixed  benign  growths  and  various  types  of  sarcoma  are  the 
chief  tumors  of  this  region.  Localized  benign  growths  can  be 
enucleated,  but  malignant  tumors  are  often  inoperable.  The 
parotid  ''Stenson's  duct"  extends  across  the  cheek  parallel  to 
and  below  the  zygomatic  arch  and  enters  the  mouth  opposite 
the  second  molar  tooth.  Infection  from  the  mouth  occasionally 
extends  along  the  duct  and  causes  suppuration  in  the 
gland.  Obstruction  of  the  duct  from  calculus  or  stricture 
may  result  in  distention,  suppuration  or  degeneration  of 
the  parotid.  Injury  to  the  duct  may  complicate  accidental  or 
operative  wounds  of  the  cheek,  resulting  in  salivary  fistula. 
Spontaneous  closure  occurs  in  simple  wounds,  but  plastic  oper- 
ative measures  are  often  required. 

The  Nose  (Fig.  32)  includes:  (1)  The  prominent  external 
structures,  skin,  and  cartilage.  (2)  The  nasal  passages,  septum, 
and  communicating  sinuses. 

(1)  External  Structures. — The  skin  covering  the  nose  is 
delicate,  with  a  slight  amount  of  subcutaneous  tissue.  The 
skin  contains  numerous  sv\reat  and  sebaceous  glands,  and  is  a 
frequent  site  of  persistent  "acne."  Erysipelas  frequently  origi- 
nates in  this  area.  Other  special  lesions  are  lupus,  tuberculosis, 
and  epithelioma.  Injuries  usually  result  in  dislocation  of  the 
cartilages,  or  fracture  at  the  base  or  "bridge"  of  the  nose, 
which  is  often  compound,  most  often  to  the  mucous  surface. 
Such  injuries  require  careful  reduction,  and  the  use  of  special 
intranasal  sphnts,  together  with  sprays  of  mild  alkaline  anti- 
septics. Penetrating  wounds  of  the  nose  which  involve  the 
non-vascular  cartilage  heal  slowly.  Syphilitic  lesions  are  likely 
9 


130      ESSENTIALS  OF  SURGERY  FOR  NURSES 

to  be  associated  with  destruction  of  the  base  or  bridge,  with 
marked  deformity. 

(2)  The  INTEENAL  STRUCTURES  of  the  nose  include  the  two 
nasal  passages  separated  by  the  cartilaginous  septum,  and  lim- 
ited by  the  lateral  walls  and  the  turbinate  bones  on  each  side, 
together   with   the   communicating   mucous   lined   "sinuses." 


Fig.  32. — The  nose  and  accessory  siniises. 

The  highly  vascular  mucous  membrane  lining  the  nasal  pas- 
sages, the  septum,  lateral  walls,  turbinates,  and  communicating 
sinuses  is  attached  to  the  cartilage  and  bone,  and  is  subject  to 
various  types  of  inflammatory  lesions. 

Acute  catarrhal  inflammation,  "coryza,"  or  common  cold,  is 
extremely  frequent  and  is  likely  to  involve  the  entire  mucous 
membrane.  Complications  are:  (1)  Changescausinghypertrophy 
of  the  mucous  membrane  and  submucous  tissues,  especially  that 
covering  the  turbinate  bones.     This  results  in  a  recurrent  and 


THE  HEAD— CRANIUM  AND  FACE  131 

persistent  catarrh,  or  obstruction  of  the  nasal  passages,  occa- 
sionally necessitating  removal  of  the  hypertrophied  turbinates. 
(2)  Pharyngitis,  and  development  of  hypertrophied  "adenoids" 
or  tonsils,  with  their  resulting  complications.  (3)  Obstruction 
to  adequate  drainage  of  one  or  more  of  the  communicating 
sinuses  and  suppuration  in  that  cavity. 

The  SINUSES  thus  involved  are:  (a)  The  maxillary  sinus,  or 
antrum  of  "Highmore,"  (6)  the  frontal  sinus,  and  (c)  the  eth- 
moid and  sphenoid  sinuses. 

(a)  The  maxillary  sinus  or  antrum  of  Highmore  com- 
municates with  the  nostril  by  means  of  an  opening  under  the 
middle  turbinate.  It  is  located  in  the  body  of  the  superior 
maxillary  bone,  being  separated  from  the  orbit  above,  the  cheek 
externally,  the  nostril  internally,  and  the  roots  of  the  upper 
molar  teeth  by  a  thin  plate  of  bone.  Suppuration  in  the  antrum 
may  be  secondary  to:  (i)  Catarrh  extending  from  the  nose 
with  inadequate  drainage  through  the  opening,  (ii)  Extension 
of  a  root  abscess  from  the  upper  teeth,  (iii)  Frontal  sinus  in- 
fection. Acute  suppuration  causes  marked  local  pain  and  ten- 
derness, and  general  reaction  of  sepsis.  Chronic  infection  may 
lead  to  recurrent  attacks  and  remote  constitutional  effects. 
The  process  is  often  obscure  and  is  discovered  only  by  special 
examination.  Principle  of  treatment:  Adequate  drainage  must 
be  obtained  and  maintained,  often  by  repeated  irrigation. 
Drainage  may  be  secured :  (i)  By  enlarging  the  normal  opening, 
(ii)  By  puncture  through  the  inferior  nasal  meatus,  (iii) 
By  puncture  through  the  root  canal  of  the  first  or  second  molar 
teeth,  (iv)  By  incision  and  opening  through  the  alveolar 
process  of  the  superior  maxillary  bone.  The  results  are  often 
striking,  but  recurrence  is  not  infrequent. 

(6)  The  FRONTAL  sinus  communicates  with  the  nostrils 
through  a  canal  which  opens  in  common  with  that  from  the 
maxillary  sinus.  Suppuration  in  the  frontal  sinus  is 
associated  with  acute  catarrh  of  the  nasal  epithelium  and 
obstruction  to  free  drainage  through  the  canal.  There  is: 
constitutional  evidence  of  sepsis,  persistent  headache,  local 
pain  and  tenderness.  Dangers:  (i)  Sepsis;  (ii)  recurrent 
attacks;  (iii)  extension  through  the  thin  plate  of  the  frontal 
bone,  and  brain  abscess  or  meningitis;  (iv)  extension  to  the 
maxillary  sinus. 


132      ESSENTIALS  OF  SURGERY  FOR  NURSES 

Principles  of  Treatment. — Adequate  drainage  may  be  obtained 
through  the  normal  canal  by  surgical  measures,  or  by  external 
exposure  through  the  forehead. 

(c)  The  ETHMOID  AND  SPHENOID  boues  Contain  air-spaces 
which  may  be  infected  from  the  frontal  sinus  or  from  the  nose, 
resulting  in  suppuration.  The  condition  is  more  obscure  and 
locahzation  of  the  septic  focus  is  difficult.  There  is  serious  dan- 
ger of  extension,  resulting  in  meningitis  or  brain  abscess.  The 
cells  can  be  reached  surgically  through  the  frontal  sinus,  but 
there  is  grave  danger  of  penetrating  to  the  meninges,  causing 
fatal  septic  meningitis. 

The  NASAL  SEPTUM  is  composed  of  the  vomer,  the  bony  pos- 
terior part,  and  the  anterior  cartilaginous  portion.  Surgical 
lesions  include:  (1)  Deflections  or  s-purs  which  may  represent 
congenital  defects  or  be  caused  by  injury  or  disease.  They  are 
significant  when  causing  partial  or  complete  obstruction  of  the 
nasal  passage  associated  with  recurrent  nasal  catarrh  or  ob- 
struction to  breathing.  In  such  cases  suitable  operative  pro- 
cedures may  be  indicated.  (2)  Perforation  of  the  septum  may 
result  from:  (a)  Imperfect  healing  of  an  operative  or  accidental 
wound.  (6)  Syphilitic  ulceration.  Surgical  repair  is  difficult 
and  often  unsatisfactory.  Specific  treatment  is  indicated  for 
syphilitic  cases. 

Epistaxis,  nose-bleed,  may  be  caused  by:  (1)  Injury  and 
rupture  of  submucous  veins,  in  which  case  it  is  usually  not 
serious  and  is  self-limited.  (2)  Nasal  catarrh  associated  with 
local  hypersemia  and  ulceration.  This  is  often  persistent  but 
is  rarely  of  serious  consequence.  (3)  By  high  general  arterial 
pressure  often  being  compensatory,  possibly  occurring  instead 
of  serious  hemorrhage  in  other  regions,  cerebral  apoplexy.  Re- 
currence is  not  uncommon.  (4)  Persistent  epistaxis  may  be  due 
to  abnormal  composition  of  the  blood,  retarding  the  normal 
coagulation  and  spontaneous  control  of  bleeding.  This  type 
may  reach  serious  proportions  being  uncontrolled  by  local 
measures.  Indications  for  treatment:  Rest  in  bed,  freedom  from 
excitement  or  exertion,  cold  compresses,  and  measures  to  re- 
duce general  blood  pressure.  Also  special  therapy  to  influence 
the  composition  of  the  blood.  (See  page  56.)  Local  treatment: 
Careful  packing  of  the  anterior  nares,  cauterization  of  the  bleed- 
ing point  where  such  can  be  found,  packing  of  the  posterior 


THE  HEAD— CRANIUM  AND  FACE  133 

nares,  and  ligation  of  the  external  carotid  in  persistent  cases 
which  are  not  otherwise  controlled. 

The  Mouth  includes:  The  lips,  gums,  alveolar  processes, 
teeth,  palate,  tonsils,  pharynx,  and  tongue. 

The  Lips,  forming  the  orifice  of  the  mouth,  are  covered 
externally  by  a  layer  of  skin,  and  are  lined  with  mucous  mem- 
brane continuous  with  that  of  the  mouth.  The  circular  ''orbic- 
ularis oris"  muscle,  together  with  blood-vessels  and  mucous 
glands,  is  found  between  the  two  layers. 

(1)  Lesions. — Congenital  deformity,  hare-lip  (see  "cleft 
palate,"  page  135),  may  occur  independently,  extending  from 
the  margin  of  the  lip  towards  or  into  the  nostril,  causing  marked 
disfigurement.    Repair  by  plastic  operation  is  indicated. 

(2)  Wounds  which  involve  the  circular  branch  of  the  facial 
artery  may  require  ligation  of  that  vessel.  Hemorrhage  is 
always  profuse,  but  is  controlled  by  suture,  which  must  secure 
accurate  apposition  to  avoid  scar.  Asepsis  in  the  after-care  is 
diflBcult  to  secure,  but  serious  wound  infection  is  rare  on  account 
of  the  rich  blood-supply.  Adhesive  strips  are  often  applied 
across  the  wound  to  reheve  tension  on  the  sutures. 

(3)  Infection,  cellulitis,  is  rarely  important  but  is  associated 
with  marked  painful  swelling  in  the  subcutaneous  tissues. 
(a)  Ulcers,  "herpes,"  cold-sores,  accompany  certain  acute 
infections:  pneumonia,  grippe,  and  colds;  consist  of  blebs  or 
water  blisters.  The  condition  is  usually  self-limited  and  of 
slight  importance,  healing  promptly  with  some  unirritating 
lotion  or  ointment.  (6)  Fissures  or  small  ulcerations  occur  as  a 
result  of  irritation.  The  base  or  crack  becomes  lined  with  tender 
infected  granulations  which  may  require  cauterization.  Fur- 
ther irritation  must  be  avoided,  after  which  prompt  healing 
should  follow.  Persistent  ulcers  suggest  malignant  epithelioma, 
(c)  Chancre  of  the  lip  occurs  in  accidental  syphilitic  infection 
and  has  a  characteristic  appearance  with  marked  swelling 
in  the  surrounding  tissues.  The  causal  "spirochseta  pal- 
lida" can  usually  be  demonstrated,  and  specific  treatment  is 
indicated. 

(4)  New-growths. — Malignant  epithelioma,  originating  in 
the  mucous  epithelium  or  that  of  the  submucous  glands,  is 
seen  most  often  in  individuals  of  middle  or  advanced  age.  There 
is  usually  a  history  of  an  ulceration  which  persists  in  spite  of 


134      ESSENTIALS  OF  SURGERY  FOR  NURSES 

ordinary  treatment.  Therefore,  one  must  suspect  any  such 
ulceration,  especially  those  showing  infiltration  about  the  base. 
Enlargement  of  the  submaxillary  lymph-nodes  is  evidence  of 
advanced  malignancy. 

Principles  of  Treatment. — Free  excision  of  the  ulcerating  area 
with  a  wide  margin  of  healthy  tissue,  and  suitable  plastic  opera- 
tion, represent  the  simplest  procedure,  justifiable  only  in  early 
or  doubtful  cases.  Otherwise,  radical  removal  with  dissection  of 
the  lymph-nodes  in  the  upper  anterior  triangles  of  the  neck  is 
indicated. 

The  Gums  include  the  mucous  membrane,  and  submucous 
tissue  covering  the  alveolar  processes  of  the  upper  and  lower 
jaw,  surrounding  the  teeth.  (1)  Infections  or  abscesses  aTeusuaWy 
secondary  to  carious  teeth,  extending  along  the  root  canal  to 
the  alveolar  bone,  and  may  be  covered  by  fillings  or  crowns,  or 
remain  quiescent  for  long  periods.  Acute  suppuration  causes 
constitutional  reaction  and,  locally,  pain,  swelling,  and 
enlargement  of  the  submaxillary  lymph-nodes.  It  is  often 
difficult  to  demonstrate  the  particular  tooth  which  is  causing 
the  disturbance.  Prompt  and  adequate  drainage  is  indicated 
and  may  be  obtained:  (a)  Through  the  root  canal  by  suit- 
able dental  work,  possible  only  in  some  cases,  (b)  Ex- 
traction of  the  tooth  involved  usually  gives  direct  drainage, 
(c)  Directly  through  the  gum  and  alveolar  process,  (d)  Rarely 
by  incision  through  the  cheek. 

(2)  Chronic  root  abscess  may  occur  in  the  absence  of  previous 
acute  suppuration  about  devitalized  teeth,  as  a  slow  process 
causing  constant  absorption  of  small  amounts  of  toxic  material 
and  remote  constitutional  effects:  Rheumatism  or  neuralgia. 
The  condition  is  recognized  by  X-ray  plates,  and  extraction  of 
the  involved  teeth  is  often  followed  by  remarkable  results. 

(3)  Pyorrhea  alveolaris  is  an  infection  of  the  gums  about 
the  roots  of  the  teeth,  caused  by  a  variety  of  micro-organisms. 
The  gums  become  soft,  bleed  easily,  the  teeth  loosen,  pus  can 
be  demonstrated,  and  there  may  be  necrosis  of  the  alveolar 
process.  The  condition  is  often  associated  with  constitutional 
disturbance,  either  as  a  cause  or  effect:  malnutrition,  anemia, 
indigestion,  and  loss  of  weight.  Treatment  includes  dental 
procedures,  constitutional  measures,  and  in  some  cases  specific 
vaccines. 


THE  HEAD— CRANIUM  AND  FACE 


135 


(4)  Tumors,  other  than  those  common  to  mucous  epithehum, 
are  rare.  Certain  benign  cysts  associated  with  abnormal  tooth 
development  are  occasionally  found.  "  Epulis,"  a  benign  fibrous 
growth,  is  not  infrequent  in  the  gums,  and  is  removed  by  local 
excision.  Recurrence  is  rare  provided  the  entire  growth  with 
a  wide  margin  of  healthy  tissue  is  removed. 

The  Palate  refers  to  the  roof  of  the  mouth,  which  is  com- 
posed of:  (A)  The  hard  palate  (Fig.  33)  formed  by  the  hori- 
zontal parts  of  the  two  superior  maxillary  bones,  and  (B)  the 
soft  palate,  composed  of  a 
fold  of  mucous  membrane  lin- 
ing the  nasal  passages  and 
the  mouth  below,  terminat- 
ing in  a  pointed  process,  the 
"uvula,"  which  hangs  freely 
between  the  mouth  and  phar- 
ynx. Lesions  include :  (1) 
Congenital  cleft.  (2)  Per- 
forations. 

(1)  Congenital  cleft  (see 
Fig.  33)  occurs  as  a  result  of 
failure  of  the  two  superior 
maxillary  bones  to  unite  com- 
pletely. The  hard  palate 
forms  by  the  fusion  of  the 
two  superior  maxillary  bones 
1  and  2,  and  a  third  pre- 
maxillarybone,3.  Congenital 
cleft  palate  may  be  double 
or  single,  extending  into  one  or  both  nostrils,  including  the 
gum,  alveolar  process  and  the  lip,  and  often  extends  as  a 
single  cleft  through  the  soft  palate.  Effects. — (a)  Deformity. 
(6)  Interference  with  nursing  and  swallowing  so  that  special 
methods  of  feeding,  by  a  dropper  or  tube,  may  be  necessary. 
Marked  malnutrition  may  result  and  demand  early  treatment, 
(c)  Interference  with  respiration  and  later  with  phonation. 
{d)  Further  separation  of  the  cleft  and  contraction  of  the  soft 
parts.  Treatment  is  surgical  repair.  The  preferable  time  is 
a  matter  of  judgment  but  is  most  often  done  within  the  first 
few  months  of  life.    The  operation  is  difficult,  especially  in 


Fig.  33. — Showing  the  development  of 
the  superior  maxillary  plate  and  palate  in 
relation  to  "cleft  palate." 


136       ESSENTIALS  OF  SURGERY  FOR  NURSES 

older  children,  but  the  results  are  usually  good  and  the  risk  is 
shght  in  the  hands  of  competent  operators.  Post-operative 
care  is  most  important.  Sutures  are  usually  reinforced  by 
adhesive  straps  across  the  cheeks.  Feeding  is  done  by  means 
of  a  tube  passed  through  the  nostril  into  the  stomach,  to  avoid 
contamination  of  the  mouth  and  wound.  Mild  antiseptic  solu- 
tions, boracic  acid,  or  alkaline  antiseptic  mixtures  are  used 
as  a  spray  or  mouth-wash. 

(2)  Perforation  of  the  palate  occurs:  (a)  As  a  result  of  com- 
plete closure  of  a  cleft,  (6)  accident,  (c)  syphilitic  ulceration. 
Repair  is  difficult  and  often  unsatisfactory.  Specific  treatment 
is  urgently  indicated  in  syphilitic  cases  to  prevent  further  de- 
struction of  tissue. 

The  Tongue  is  a  muscular  organ  attached  to  the  lower  jaw 
and  hyoid  bone.  It  is  covered  "'.vith  mucous  membrane  which 
contains  the  special  taste  cells  and  nerve  endings,  also  mucous 
secretory  glands.  MechanicaUy  it  aids  in  swallowing  and  in 
articulation. 

(1)  Wounds  are  rare,  bleeding  is  profuse,  and  healing  is 
usually  rapid,  wound  infection  being  infrequent  on  account  of 
the  rich  blood-supply. 

(2)  Ulcers  occur  as  a  result  of  persistent  irritation  from 
broken  teeth  and  are  associated  with  considerable  induration, 
to  a  degree  suggesting  a  malignant  growth.  Removal  of  the 
cause  is  indicated,  after  which  the  condition  should  clear  up. 
Syphihtic  ulcers  are  rare,  but  simulate  malignant  growths. 

(3)  Tumors. — Benign  cysts  are  rare,  but  may  reach  con- 
siderable size.  Enucleation  of  the  mass,  while  technically  diffi- 
cult, is  not  followed  by  recurrence.  Mahgnant  cancer  from 
the  mucous  membrane  begins  as  an  ulcer  which  does  not  heal 
even  when  the  apparent  source  of  irritation  has  been  removed. 
Extension  to  the  submaxillary  gland  is  early.  Prompt  radical 
excision  is  indicated  and  is  successful  in  a  fair  percentage  of 
eases.  It  is  a  formidable  operation,  consisting  of  complete  re- 
moval of  the  tongue  and  lymph-nodes  in  the  anterior  triangle 
of  the  neck,  but  the  mutilation  is  not  as  great  as  might  be 
expected. 

(4)  "Tongue-tie^'  refers  to  an  abnormally  short  "frenum," 
or  the  fold  of  mucous  membrane  from  the  tip  of  the  tongue  to 
the  floor  of  the  mouth.    It  occurs  rarely  in  the  new-born,  and  is 


THE  HEAD— CRANIUM  AND  FACE  137 

supposed  to  interfere  with  nursing  and  later  with  articulation. 
Treatment,  when  indicated,  consists  of  division  of  the  frenum 
with  scissors. 

The  floor  of  the  mouth  under  the  tongue  covers  the  sub- 
maxillary and  sublingual  salivary  glands.  The  principal 
surgical  lesion  is  "ranula,"  a  retention  cyst  of  the  salivary 
gland  or  its  duct.  Such  a  tumor  may  reach  considerable  size 
and  interfere  with  movements  of  the  tongue.  Treatment:  (1) 
Reestabhshment  of  the  patency  of  the  duct.  (2)  Excision 
of  the  mass. 

The  Throat  or  Pharynx  is  continuous  with  the  mouth 
at  the  "fauces,"  i.e.,  the  folds  of  mucous  membrane  which 
extend  from  the  uvula  and  soft  palate  to  the  base  of  the 
tongue.  The  pharynx  includes :  (1)  The  Naso-pharynx,  above 
the  level  of  the  soft  palate,  continuous  with  the  nasal  pas- 
sages in  front,  in  the  lateral  wall  receives  the  openings  of  the 
Eustachian  tubes  which  communicate  with  the  middle  ear,  and 
contains  the  masses  of  lymphoid  tissue,  the  ''adenoids."  (2)  The 
Oro-pharynx,  at  the  level  of  the  mouth,  including  the  tonsils. 
(3)  The  Laryngo-pharynx,  below  the  base  of  the  tongue, 
receiving  the  openings  of  the  oesophagus  and  larynx.  Lesions 
of  interest  are: 

The  Tonsils,  composed  of  lymph  tissue,  are  limited  at  the 
base  by  a  definite  capsule  and  are  located  between  the  "pillars  of 
the  fauces."  Acute  inflammation,  tonsillitis,  is  frequent  either  as 
an  independent  infection,  or  complicating  certain  general  infec- 
tious diseases  (scarlet  fever,  measles,  or  diphtheria)  and  is  usu- 
ally due  to  some  type  of  streptococcus.  It  is  associated  with 
constitutional  symptoms,  fever,  toxemia,  and  pain,  both  local 
and  general.  Duration  is  usually  a  few  days.  Complications: 
(1)  Peritonsillar  abscess,  or  "quinsy, "  occurs  in  some  cases  as  a 
painful  swelling  in  the  peritonsillar  tissues,  usually  of  the  soft 
palate.  In  favorable  cases  spontaneous  recovery  takes  place  in 
a  few  days,  while  in  others  suppuration  develops.  In  this 
event  the  condition  persists  till  spontaneous  rupture  or  surgical 
incision  provides  drainage.  (2)  Cervical  adenitis  is  not  uncom- 
mon. (3)  Hypertrophy  and  chronic  inflammatory  changes  in 
the  tonsil,  with  recurrent  attacks.  (4)  Constitutional  effects, 
rheumatism,  acute  or  chronic,  heart  lesions.  (5)  Pharyngitis 
and  chronic  infection  of  the  adenoids.     This  may  also  occur 


138      ESSENTIALS  OF  SURGERY  FOR  NURSES 

independently  of  the  tonsils,  associated  with  local  pain  and 
general  effects.  (6)  Extension  through  the  Eustachian 
tube  and  infection  of  the  middle  ear. 

Principles  of  Treatment. — During  an  acute  attack,  consist  of 
local  applications  (silver  nitrate  or  iodine  solutions)  and  con- 
stitutional measures.  Surgical  removal  is  rarely  considered 
during  an  acute  attack,  but  is  indicated  when  there  are  recur- 
rent attacks  or  persistent  complications. 

The  adenoids  of  the  naso-pharynx  are  frequently  inflamed 
and  hypertrophied  in  young  children,  either  associated  with  or 
independent  of  the  tonsils.  The  effects  are:  (1)  Mechanical 
interference  with  normal  respiration  and  secondary  constitu- 
tional changes  in  development.  (2)  Recurrent  attacks  of 
catarrh,  pharyngitis,  and  bronchitis.  Removal  is  indicated 
for  either  condition,  and  is  a  simple  operation  which  can  be 
done  at  any  age. 

The  LOWER  JAW,  or  inferior  maxillary  bone,  articulates  with 
the  temporal  in  front  of  the  external  auditory  meatus. 

Dislocation  forward  occurs:  (1)  Spontaneously  as  a  result 
of  sudden  forcible  movements,  yawning.  (2)  Sudden  down- 
ward pressure  on  the  open  jaw,  especially  under  anaesthesia,  by 
a  mouth-gag  or  tongue  depressor.  The  jaw  is  held  open 
and  protruded  and  cannot  be  closed.  Reduction  under  an 
anaesthetic  is  simple,  and  may  also  occasionally  be  accom- 
plished without,  by  downward  pressure  well  back  near  the 
angle  of  the  jaw. 

Infectious  processes  occur  similar  to  those  of  the  upper  jaw. 

Fracture  takes  place  most  often  to  one  side  of  the  mid-line, 
and  is  likely  to  be  compound  into  the  mouth.  Reduction  is 
usually  simple,  but  immobilization  is  extremely  difficult.  Some 
form  of  dental  appliance  is  necessary.  Non-union  or  excessive 
callus  is  not  infrequent. 

DEMONSTRATIONS. 

1.  The  conjunctiva  and  openings  of  the  tear-ducts  on  patient. 

2.  Method  of  removal  of  foreign  body,  reflection  of  Uds,  irrigation  and 

instillation,  application  of  pressure  bandage. 

3.  History  of  case  of  sympathetic  ophthalmia. 

4.  Cases  of  blindness  or  specific  histories,  with  explanation  of  cause. 

5.  History  of  a  penetrating  wotmd  of  the  orbit  with  compUcations. 

6.  Case  of  facial  paralysis  with  explanation  of  cause  and  results. 

7.  Trifacial  neuralgia. 


THE  HEAD— CRANIUM  AND  PACE  139 

8.  Demonstration  of  facial  artery  and  practice  of  counting  of  pulse  in 

that  vessel. 

9.  Swelling  of  parotid  gland. 

10.  Demonstration  of  nasal  septum  and  turbinates  with  a  speculum,  also 

showing  anomalies. 

11.  Demonstration  of  the  "accessory  sinuses"  on  a  skull  cut  to  expose  them. 

12.  Methods  of  control  of  nose-bleed. 

13.  Demonstration  of  ulcers  of  the  lip,  and  if  possible  epithelioma. 

14.  Case  of  cleft-palate,  showing  methods  of  feeding  preceding  and  fol- 

lowing operation. 

15.  Demonstration  of  the  tongue,  frenum,  and  relations  to  "tongue-tie." 

16.  Demonstration  of  the  tonsils  and  phar3mx. 

17.  Case  history  of  a  case  of  tonsillitis  with  compHcations. 

18.  Apparatus  for  immobilization  of  fracture  of  the  lower  jaw. 


CHAPTER  IX 

THE  NECK,  CERVICAL  REGION 

The  limits  of  this  region  are:  The  mastoid  process  and 
lower  jaw  above,  and  the  clavicle,  or  "shoulder-bone,"  below. 
The  structures  v/hich  present  surgical  interest  include:  Su- 
perficial landmarks;  blood  vessels;  nerves;  lymph-nodes; 
thyroid;  larynx  and  trachea;  oesphagus;  vertebral  column, 

A.  The  principal  surgical  landmarks  are:  (1)  Bony:  the 
spinous  process  of  the  seventh  or  eighth  cervical  vertebra, 
which  marks  the  lower  level  of  the  neck  posteriorly.  The 
cricoid  cartilage,  or  "Adam's  apple,"  is  easily  palpable  and 
forms  the  anterior  wall  of  the  larynx.  It  can  be  seen  to  move 
during  swallowing.  (2)  Muscular:  the  sterno-cleido-mas- 
toid  muscle  can  be  seen  or  palpated,  extending  from  the  sternum 
to  the  mastoid  process,  and  divides  the  neck  into  the  "anterior 
and  posterior  triangles."  Throughout  most  of  its  course  the 
muscle  covers  the  carotid  arteries  and  the  deep  jugular  veins. 
The  trapezius  muscle  can  be  palpated,  extending  from  the  tip 
of  the  shoulder  to  the  occiput  of  the  skull,  and  with  the  clavicle 
and  posterior  border  of  the  sterno-cleido-mastoid  muscle,  forms 
the  "posterior  triangle"  of  the  neck.  Accidental  wounds  of  the 
neck  are  of  most  importance  when  the  larger  vessels  or 
trachea  are  involved. 

B.  Vessels. — (1)  Veins:  (a)  The  superficial  jugular  veins 
are  often  visible,  especially  when  the  neck  is  compressed  or 
there  is  venous  congestion.  Hemorrhage  from  these  veins  is 
profuse  but  can  usually  be  controlled  by  compression,  and 
if  promptly  cared  for  is  not  fatal.  (6)  The  internal  jugular 
veins  accompany  the  carotid  arteries,  under  the  sterno-cleido- 
mastoid  muscle.  Hemorrhage  from  these  vessels  is  rapidly 
fatal  unless  prompt  surgical  control  is  possible. 

Thrombosis  of  the  jugular  veins  is  an  occasional  complica- 
tion of  the  middle  ear  or  mastoid  suppuration.      Surgical  ex- 
cision of  the  thrombosed  vein  is  sometimes  done  to  prevent 
septic  emboli  from  reaching  the  heart  and  general  circulation. 
140 


THE  NECK,  CERVICAL  REGION  141 

(2)  The  Carotid  arteries  include  the  common  caro- 
tids and  their  two  branches,  (a)  The  external  carotids  supply  the 
neck,  face,  and  scalp,  and  (6)  the  internal  carotids,  with  the  two 
vertebrals,  form  the  anastomotic  "circle  of  Willis"  and  supply 
the  brain.  The  carotid  vessels  reach  the  neck  under  the  clavicle 
posterior  to  the  sterno-cleido-mastoid  muscle,  pass  upwards 
beneath  this  muscle,  and  finally  under  its  anterior  border 
behind  the  angle  of  the  jaw.  Hemorrhage  from  wounds  of  the 
carotids  or  one  of  the  principal  branches  is  rapidly  fatal  unless 
promptly  controlled.  Ligation  of  the  external  carotid  is  usually 
compensated  by  collateral  circulation,  and  may  be  necessary  to 
control  bleeding  from  one  of  its  branches.  Ligation  of  the 
internal  or  common  carotid  is  often  followed  by  serious  dis- 
turbance in  the  cerebral  circulation,  evident  by  faintness  or 
temporary  unconsciousness,  but  is  rarely  fatal. 

C.  Nerves. — 1.  Spinal  accessory,  the  "eleventh  cranial" 
nerve  to  the  trapezius  muscle,  crosses  the  posterior  triangle  of 
the  neck.  It  is  sometimes  cut  in  operations  for  the  removal 
of  enlarged  adherent  lymph-nodes.  There  follows  a  paralysis 
of  the  dependent  muscle,  with  characteristic  shoulder-drop 
and  inabihty  to  raise  the  shoulder  or  arm  above  that  level. 

(2)  The  Vagus,  "pneumo-gastric  "or  "tenth  cranial "  nerve, 
passes  through  the  neck  under  the  carotid  and  jugular  vessels. 
Accidental  injury  is  rare,  but  pressure  on  the  nerve  from  tumors 
or  aneurism  may  cause  marked  disturbance  in  the  circulation. 
The  recurrent  laryngeal  branches  of  the  vagus  to  the  vocal 
cords  pass  in  close  relation  to  the  thyroid  gland.  It  is  occasion- 
ally injured  in  operations  on  that  gland,  resulting  in  paralysis  of 
the  corresponding  vocal  cord. 

(3)  The  Brachial  plexus  (see  Fig.  28)  of  the  spinal'nerves 
to  the  upper  extremity  crosses  the  lateral  region  of  the  neck. 
Parts  of  it  may  be  severed  or  torn  as  a  result  of:  (a)  Injury 
during  birth.  (6)  Stab  or  gunshot  wounds,  (c)  Severe 
wrenching  of  the  arm.  There  results  a  permanent  paralysis 
and  disturbance  of  sensation  involving  definite  portions  of  the 
upper  extremity.  After  the  extent  of  permanent  disability 
has  been  determined,  surgical  exposure  and  suture  of  the  sev- 
ered nerve  trunks  is  indicated  and  feasible. 

D.  Lymph-nodes. — Superficial  and  deep  chains  of  nodes 
extend  in  both  the  anterior  and  posterior  triangles  of  the  neck, 


142      ESSENTIALS  OF  SURGERY  FOR  NURSES 

the  deep  chain  being  in  close  relation  to  the  large  vessels.  The 
cervical  lymph-nodes  receive  the  lymphatic  drainage  from  the 
scalp,  ears,  face,  teeth,  tonsils,  and  neck,  and  also  communicate 
with  the  axillary  and  thoracic  chains.  They  may  therefore  be 
involved  secondarily,  in  infectious  or  malignant  processes,  in 
any  of  the  above  tributary  areas. 

Infections  may  be :  (1)  Acute  inflammation  of  the  cervical 
lymph-nodes  is  caused  most  often  by  superficial  abscess,  or 
infection  about  the  mouth,  teeth,  or  throat,  as  in  tonsillitis, 
scarlet  fever,  or  measles.  The  effects  are  the  same  as  lymph- 
node  involvement  in  general.  (See  page  97.)  Possible  results 
are :  (a)  The  process  gradually  subsides  without  suppuration, 
provided  the  original  focus  is  self-limited  or  is  controlled  by 
treatment.  (6)  The  involvement  of  the  lymph-nodes  goes  on 
to  suppuration  and  extends  to  adjacent  tissues,  resulting  in  a 
diffuse  abscess  which  must  be  treated  independently  of  the 
original  focus. 

Principles  of  Treatment. — (i)  Measures  to  control  the  origi- 
nal focus  of  infection,  (ii)  Constitutional  treatment  of  the 
fever  and  sepsis,  (iii)  Local  application  or  an  ice-bag,  to  the 
involved  region,  (iv)  Surgical  incision  and  drainage  when 
suppuration  is  evidently  present. 

(2)  Chronic  inflammation  includes:  (a)  Tuberculosis,  and 
(6)  Hodgkin's  disease. 

(a)  Tuberculosis  (see  page  36)  of  the  cervical  glands 
may  develop  from  a  portal  of  entry  in  the  area  of  drainage 
(mouth  or  throat),  or  secondarily  to  a  pulmonary  lesion,  either 
of  which  may  have  been  unrecognized.  It  occurs  most  often  in 
children  or  young  adults,  and  the  development  is  insidious. 
There  is  often  constitutional  evidence  of  tuberculosis,  but  the 
patients  are  often  well  nourished.  The  nodes  are  enlarged,  and, 
in  the  early  stage,  discrete.  Suppuration  occurs  later,  often 
being  due  to  secondary  infection,  and  there  results  a  diffuse 
mass  of  densely  adherent  lymph-nodes.  The  course  is  chronic, 
extending  over  a  period  of  months,  and  recurrence  is  frequent. 

Principles  of  Treatment. — (i)  Constitutional  and  specific 
therapy  for  tuberculosis,  (ii)  Local,  incision  and  drainage  is 
reserved  as  a  last  resort,  on  account  of  the  danger  of  secondary 
infection  and  persistent  sinus.  Radical  dissection  of  the  entire 
mass  of  nodes  is  sometimes  done  in  selected  cases. 


THE  NECK,  CERVICAL  REGION  143 

(6)  Hodgkin's  disease  is  a  chronic  inflammatory  process 
involving  the  lymph-nodes,  especially  in  the  cervical  region, 
caused  by  a  specific  micro-organism.  The  onset  is  insidious, 
and  the  portal  of  entry  is  often  obscure.  There  is  marked  en- 
largement of  the  lymph-nodes  Mdth  characteristic  microscopic 
changes.    Suppuration  is  rare. 

Principles  of  Treatment. — (i)  Constitutional  and  specific  by 
serums  or  vaccines,  (ii)  Surgical  removal  of  the  enlarged 
lymph-nodes 

(c)  Malignant  growths  in  the  area  drained  by  the  cervical 
lymph-nodes  is  soon  accompanied  by  moderate  enlargement  of 
these  structures.  The  nodes  are  palpable  and  discrete.  Micro- 
scopical examination  of  an  excised  node  demonstrates  the  presence 
of  metastatic  growth  of  the  tumor.  Significance. — (1)  The  early 
extension  of  all  malignant  growths  to  these  nodes  is  an  indica- 
tion for  the  radical  dissection  of  the  cervical  lymphatics  in  all 
operations  for  malignant  disease  in  the  tributary  area.  (2)  The 
actual  presence  of  enlarged  nodes  in  a  given  case  is  evidence 
that  the  growth  is  no  longer  local,  and  gives  a  less  favorable 
prognosis. 

E.  The  ThjToid  gland  is  a  glandular  structure  consisting  of 
two  lobes,  one  on  each  side  of  the  trachea,  covered  by  the 
sterno-hyoid  muscles,  and  connected  by  a  narrow  portion,  or 
the  "isthmus,"  which  crosses  in  front  of  the  trachea.  The 
gland  develops  embryologically  as  an  out-growth  from  the  floor 
of  the  mouth  in  the  region  of  the  "foramen  caecum,"  at  the  base 
of  the  tongue.  This  connection  is  normally  lost  early  in  devel- 
opment, but  the  origin  explains  the  occasional  development  of 
masses  of  aberrant  thyroid  tissue  higher  in  the  neck,  or  in  the 
base  of  the  tongue.  Function:  The  thyroid  furnishes  an  essen- 
tial internal  secretion  which  controls  development  during 
childhood,  and  influences  body-metabolism  throughout  life. 

Abnormalities  in  Function. — 1.  Athyroidism,  "cretinism," 
is  due  to  congenital  absence  of  functioning  thyroid  tissue  and  is 
characterized  by  dwarfed  stature,  mental  deficiency  or  idiocy, 
typical  over-development  of  subcutaneous  tissue,  and  thickened 
skin.  2.  Myxedema  hypothyroidism,  due  to  deficient  thyroid 
secretion  may  be:  (a)  Congenital,  (6)  develop  spontaneously 
at  any  age,  or  (c)  follow  extensive  loss  of  thyroid  tissue  by  disease 
or  operation.    The  results  vary  in  degree  and  include  mental 


144      ESSENTIALS  OF  SURGERY  FOR  NURSES 

changes,  depression,  sluggishness  or  semi-stupor;  the  circu- 
lation is  poor  and  the  extremities  are  easily  chilled,  the  sub- 
cutaneous tissues  are  overdeveloped,  with  thickening  of  the 
skin,  and  a  characteristic  wooden,  immobile  expression  of  the 
face.  The  condition  is  obscure  in  development  and  is  easily- 
overlooked.  Treatment  is  specific,  i.e.,  feeding  thjrroid  extract 
in  proper  doses,  and  gives  striking  results.  Spontaneous  read- 
justment may  occur  during  treatment,  but  in  some  cases  the 
feeding  must  be  continued  indefinitely.  3.  Hyperthyeoid- 
ISM,  due  to  the  absorption  of  an  excessive  amount  of  normal  or 
abnormal  thyroid  secretion,  is  known  as  "exophthalmic 
goiter"  (see  later). 

Goiters  or  enlargements  of  the  thyroid  include  four  groups: 
(1)  Simple  hypertrophy;  (2)  simple  goiter;  (3)  toxic  goiter, 
and  (4)  mahgnant  growths. 

(1)  Simple  general  hypertrophy  of  the  thyroid  often  occurs 
as  a  compensatory  process  to  meet  unusual  demands  for 
thyroid  secretion,  particularly  during  puberty  or  pregnancy, 
also  less  often  in  the  male  at  puberty.  Since  the  condition 
is  compensatory  and  self-limited,  treatment  is  usually  not 
indicated. 

These  goiters  are  not  infrequent  and  may  be  a  source  of 
alarm  to  the  patient  or  her  family.  As  a  rule  one  may  give 
assurance  that  the  condition  will  subside  spontaneously.  Should 
it  persist  or  increase,  or  should  constitutional  symptoms  de- 
velop, competent  surgical  advice  should  be  obtained. 

(2)  Simple  goiters  include  a  variety  of  pathological  changes 
such  as  atypical  development,  cystic  or  colloid  degeneration. 
The  enlargement  may  be  definitely  limited  and  encapsulated, 
or  more  diffuse.  The  simple  goiters  cause  only  mechanical 
effects  from  pressure  on  neighboring  structures.  Example:  On 
the  trachea,  causing  dyspnoea,  or  asthma.  In  some  cases  it 
may  undergo  changes  and  give  rise  to  toxic  S3anptoms  resem- 
bling the  early  stage  of  exophthalmic  goiter.  There  is  often 
marked  enlargement  and  deformity,  also  extension  of  the 
growth  to  the  thoracic  cavity  causing  serious  compression  of  the 
trachea  or  great  vessels.  Non-surgical  treatment  is  rather  in- 
definite; but  local,  and  in  some  cases  specific  measures,  thyroid 
feeding,  may  be  of  value.  The  use  of  iodine  either  locally  or 
internally  as  frequently  advised  may  cause  serious  effects  and 


THE  NECK,  CERVICAL  REGION  145 

is  to  be  used  only  under  the  direction  of  the  surgeon.  Surgical 
removal  of  localized  tumors  or  partial  thyroidectomy  is  indica- 
ted in  case  of:  (a)  Excessive  growth  and  deformity.  (6)  Se- 
rious pressure  symptoms,  (c)  Evidence  of  extension  to  the 
thorax,     (d)  Toxic  effects. 

(3)  Toxic  goiter,  exophthalmic  goiter,  or  "Graves' 
disease, "  is  characterized  by  a  group  of  symptoms  due  to  the 
absorption  of  an  increas.ed  amount  of  thyroid  secretion,  or  pos- 
sibly, an  abnormal  secretion  due  to  degeneration  of  a  goiter. 
The  picture  may  be  only  partial,  or  complete,  including:  (a) 
Circulatory  changes,  "tachycardia,"  rapid  heart-beat,  120  to 
150,  later  cardiac  murmurs,  dilation  and  irregular  pulse.  (6) 
Nervousness  and  irritability:  flushing  of  the  face,  and  charac- 
teristic tremor  of  the  hands,  (c)  Eye  changes,  "exophthalmos, " 
prominent,  protruding  eyeballs;  failure  of  the  upper  lid  to 
completely  close,  (d)  Gastro-intestinal  symptoms:  vomiting 
and  diarrhoea  in  severe  cases.  The  course  is  usually  progressive, 
with  remissions.  Improvement  and  cure  may  follow  judicious 
medical  treatment :  rest-cure,  sedatives,  and  avoiding  all  irrita- 
tion and  nervous  factors.  Surgical  treatment  is  indicated  in 
persistent  cases,  or  those  not  influenced  by  careful  medical 
measures.  It  includes:  (1)  Ligation  of  one  or  more  of  the  thy- 
roid arteries  to  cut  off  part  of  the  blood-supply.  (2)  Partial 
thyroidectomy. 

(4)  Malignant  growths,  usually  cancer,  occur  in  older  indi- 
viduals and  are  characterized  by  rapid  diffuse  growth,  and  early 
pressure  effects. 

F.  Larynx  and  Trachea. — The  Larynx  is  composed  of  sev- 
eral cartilages,  including  the  prominent  "cricoid"  cartilage,  or 
Adam's  apple.  It  contains  the  vocal  cords,  is  continuous  with 
the  trachea  below,  and  opens  to  the  pharynx  above.  The  "epi- 
glottis" cartilage  protects  the  opening  of  the  larynx  and  prevents 
food  and  saliva  from  entering  the  larynx  or  trachea.  Surgical 
interest  includes:  (1)  Occlusion  of  the  larjTix  by  foreign  bodies. 
(2)  Inflammation,  oedema,  or  membrane.    (3)  New-growths. 

1.  Foreign  bodies  may  be  aspirated  during  anaesthesia  or 
unconsciousness,  or  by  sudden  inspiration  while  swallowing. 
They  may  lodge  in  the  larynx  or  pass  into  the  trachea.  If  loca- 
ted in  the  larynx,  they  are  often  expelled  by  coughing,  or  in- 
version of  the  patient.  When  the  opening  is  entirely  occluded 
10 


146      ESSENTIALS  OF  SURGERY  FOR  NURSES 

strangulation  is  imminent,  and  tracheotomy  is  indicated  as  an 
emergency. 

(2)  (Edema,  of  the  glottis,  i.e.,  of  the  membrane  lining  the 
larynx  and  vocal  cords,  is  an  occasional  complication  of  in- 
flammatory conditions  about  the  throat,  burns,  or  inhalation  of 
irritating  gases.  The  condition  may  develop  gradually  and  give 
warning  by  difficult  breathing  or  "croupy  attacks."  In  some 
instances  the  CBdema  is  rapidly  progressive,  and  sufficient  to 
occlude  the  larynx,  threatening  strangulation. 

Principles  of  treatment  include :  Relief  of  the  causal  condi- 
tion, the  use  of  sprays  or  inhalation  of  astringents,  adrenalin, 
steam  with  paregoric  or  camphor,  and  intubation  or  trache- 
otomy in  urgent  cases. 

Intubation  consists  of  the  insertion  of  a  hollow  silver  tube 
through  the  partially  occluded  lar3rnx,  by  means  of  special 
apparatus.  The  procedure  requires  an  expert  and  is  not  always 
successful.  "  Membranous  croup, "  which  is  usually  diphtheritic, 
is  a  common  cause  of  laryngeal  obstruction.  It  may  occur  in 
neglected  cases  of  diphtheria,  or  apparently  as  the  initial  symp- 
tom of  the  disease.  Prompt  recognition  of  the  condition  is 
important,  and  specific  treatment  with  large  doses  of  antitoxin 
is  urgently  indicated.  In  all  cases  where  there  is  any  suggestion 
of  laryngeal  obstruction  arrangements  must  be  made  to  have 
immediate  access  to  proper  instruments  for  intubation  and 
tracheotomy,  and  to  an  expert  operator. 

The  vocal  cords  consist  of  musculo-membranous  folds  ex- 
tending across  the  larynx.  They  are  supplied  by  the  recurrent 
laryngeal  branch  of  the  vagus,  which  may  be-  irritated  or  in- 
jured by:  Thyroid  tumors,  aneurisms,  or  operation,  resulting  in 
hoarseness,  or  aphonia,  and  paralysis  of  the  corresponding  cord. 

(3)  Tumors:  (1)  Benign  polyps  interfere  with  the  voice, 
cause  hoarseness  or  aphonia,  and  are  discovered  by  special 
examination.  They  may  be  removed  through  the  mouth  and 
pharynx,  or  in  special  cases  by  external  exposure  through  the 
larynx.  (2)  Mahgnant  growths,  epithelioma,  if  recognized 
early,  may  be  removed  by  radical  excision  of  the  larynx  with  a 
fair  prognosis  for  permanent  cure. 

The  Trachea  or  "windpipe"  is  continuous  with  the  larynx 
above,  extends  through  the  anterior  region  of  the  neck,  under 
the  sternum,  where  it  divides  into  the  right  and  left  bronchus, 


THE  NECK,  CERVICAL  REGION  147 

which  pass  to  the  corresponding  lung,  subdividing  into  smaller 
bronchi  and  bronchioles.  It  is  lined  with  ciliated  epithelium 
and  is  further  composed  of  a  dense  fibrous  membrane  reinforced 
by  a  series  of  cartilaginous  rings  which  protect  the  lumen  from 
collapse  or  compression. 

Points  of  surgical  interest:  (1)  Injury.  (2)  Pressure.  (3) 
Occlusion.     (4)  Tracheotomy. 

(1)  External  Injury. — Wounds  opening  into  the  trachea 
are  not  necessarily  fatal.  Dangers:  (a)  Collapse  of  the  trachea. 
(b)  Occlusion  by  blood-clots,  and  strangulation,  (c)  Infection, 
and  septic  pneumonia,  (d)  Suppuration  of  surrounding  tissues, 
extending  to  the  thorax  and  mediastinum. 

(2)  Compression  by  external  violence  may  fracture  the 
cartilage  rings  or  cause  swelhng  of  the  mucous  membrane,  pos- 
sibly with  complete  occlusion.  Since  the  trachea  is  loosely 
attached  to  the  surrounding  structures,  it  may  be  forced  to  the 
side  and  often  escapes  serious  injury.  Pressure  from  tumors, 
usually  of  the  thyroid,  if  unilateral,  causes  deviation  of  the 
trachea  with  more  or  less  occlusion  of  the  lumen.  Bilateral 
compression  results  in  marked  narrowing  of  the  lumen,  causing 
difficult  respiration  and  a  tendency  to  asthma. 

(3)  Aspiration  of  foreign  bodies  which  pass  the  lar3nix  re- 
sults in  occlusion  of  the  trachea  or  one  of  the  bronchi,  with 
strangulation  if  the  trachea  is  involved;  or  if  one  of  the  bronchi 
is  occluded,  the  dependent  portion  of  the  lung  is  thrown  out  of 
function,  resulting  in  gangrene  or  abscess.  Removal  of  the 
foreign  body  is  sometimes  possible  through  the  larynx  by  means 
of  special  instruments  in  the  hands  of  experts.  In  urgent  cases 
tracheotomy  is  necessary. 

?  (4)  "Tracheotomy"  is  the  operation  of  making  an  artificial 
opening  into  the  trachea  to  permit  free  respiration.  It  is  done : 
(a)  In  emergencies,  when  the  larynx  or  trachea  is  occluded  and 
everything  is  sacrificed  to  obtain  instant  relief.  (6)  As  a  pre- 
liminary to  extensive  operations  about  the  mouth.  Provision 
must  be  made  for  some  means  of  maintaining  the  opening  in 
the  trachea,  and  to  prevent  the  aspiration  of  blood  or  mucous. 
The  dangers  are  those  of  external  wounds  of  the  trachea:  (i) 
Collapse  of  the  trachea,  and  failure  of  respiration,  (ii)  Aspi- 
ration of  blood  or  mucous  with  strangulation,  or  later  septic 
pneumonia,     (iii)  Infection  of  surrounding  tissues,  especially 


148      ESSENTIALS  OF  SURGERY  FOR  NURSES 

when  the  tracheotomy  is  made  low  in  the  neck,  and  extension 
to  the  mediastinum. 

G.  The  CEsophagus  or  "gullet"  extends  from  the  pharynx 
behind  the  trachea  and  is  thus  protected  from  external  injury. 
It  can  be  exposed  surgically  in  the  neck.  Surgical  interest  is 
limited  to:  (1)  Injury  and  strictures  from  swallowing  foreign 
bodies,  irritating  caustic  substances.    (2)  Ulcers.    (3)  Cancer. 

1.  Foreign  bodies  which  reach  the  oesophagus  usually 
pass  into  the  stomach  or  can  be  forced  there  by  a  tube,  under 
anaesthesia.  In  case  one  is  lodged  in  the  gullet,  there  is  danger 
of  ulceration  and  rupture  to  the  mediastinum.  Removal  is 
usually  possible  through  external  exposure  in  the  neck.  Caus- 
tics and  irritating  substances,  including  acids  and  strong  alkalis, 
may  be  swallowed  accidentally,  or  with  suicidal  intent. 

The  results  are:  (a)  Ulceration  which  may  penetrate  to 
the  mediastinum.  (6)  Stricture  from  the  healing  of  such  an 
ulcer,  (i)  Permeable  strictures  permit  the  passage  of  fluid,  and 
can  usually  be  dilated  by  suitable  means,  and  do  not  present 
immediate  danger  of  starvation,  though  further  narrowing  may 
occur,  (ii)  Impermeable  stricture  does  not  allow  the  passage 
of  fluids  or  small  sounds.  Starvation  is  imminent  unless  the 
condition  can  be  improved  or  nutrition  can  be  supplied  by 
other  channel,  rectal  feeding,  or  gastrostomy  wound. 

Dilatation  of  the  gullet  above  a  stricture  may  reach  consid- 
erable size,  and  is  characterized  by  the  regurgitation  of  food  or 
fluids.  X-ray  examination  after  taking  bismuth  mixtures  dem- 
onstrates the  condition.  Principles  of  treatment:  (a)  Relief  of 
irritation  of  the  stricture  or  ulcer  by  withholding  food  by 
mouth.  (6)  Rectal  feeding,  (c)  Gastrostomy  in  more  pro- 
longed cases,  (d)  Dilatation  by  the  use  of  sounds  or  hydro- 
static pressure. 

2.  Inflammatory  ulcers,  except  those  due  to  irritating 
substances,  are  rare. 

3.  IVIalignant  disease  is  usually  cancer,  resulting  in  ulcera- 
tion and  stricture  formation,  which  finally  becomes  impermeable. 
Palliative  measures  include  rectal  feeding  and  gastrostomy. 
Surgical  removal  is  exceedingly  formidable. 

H.  The  cervical  portion  of  the  Vertebral  column  presents 
the  following  surgical  lesions:  (1)  Cervical  rib.  (2)  Fracture 
and  dislocation.    (3)  Disease. 


THE  NECK,  CERVICAL  REGION  149 

1.  Cervical  rib,  an  incomplete  rib  attached  to  the  last 
cervical  vertebra,  occurs  as  a  rare  congenital  anomaly.  It  is 
usually  unilateral,  and  may  or  may  not  be  attached  to  the 
sternum.  Effects:  Pressure  on  the  brachial  plexus  with  motor 
or  sensory  disturbance  in  the  upper  extremity.  Also,  pressure 
on  the  axillary  vessels,  possibly  causing  an  aneurism.  Surgical 
removal  is  possible. 

2.  Vertebral  fracture  and  dislocation  occur  associated 
as  the  result  of  violence.  Pressure  on  the  cord  causes  serious 
disturbance,  and  the  result  is  likely  to  be  fatal.  In  rare  cases 
exposure,  with  reduction,  is  possible. 

3.  Disease,  usually  tuberculosis,  "Pott's  disease,"  may 
involve  the  cervical  region.  Deformity  is  marked  with  serious 
pressure  on  the  spinal  cord.  " Retro-pharyngeal  abscess"  is  a 
serious  complication  because  of  the  danger  of  spontaneous 
rupture  into  the  pharynx,  with  strangulation  or  septic  pneu- 
monia. 

DEMONSTRATIONS 

1.  Demonstration  of  bony  and  muscular  landmarks  of  neck  on  a  model 

or  patient. 

2.  Demonstration  of  the  arteries  of  the  neck  and  the  "circle  of  WiUis"  on 

an  anatomical  chart. 

3.  Case  demonstration  showing  paralysis  of  the  spinal  accessory  nerve. 

4.  Case  showing  acute  cervical  adenitis  with  explanation  of  cause. 

5.  Case  of  tubercular  cervical  adenitis. 

6.  Case  or  illustration  of  Hodgkin's  disease. 

7.  Cancer  of  the  face,  tongue  or  Up,  with  involvement  of  cervical  glands. 

8.  Case  or  illustrations  showing  cretinism,  and  myxodema. 

9.  Cases  or  histories  illustrating  various  forms  of  goiter. 

10.  Demonstration  of  the  parts  of  the  larynx  on  model  or  charts. 

11.  Methods  of  treating  laryngeal  obstruction. 

12.  Apparatus  for  intubation,  technique  of  after-care. 

13.  Instruments  for  tracheotomy  and  care  of  wound. 

14.  X-ray  plate  showing  stricture  of  the  oesophagus  with  dilatation  above. 

15.  Soimds  and  apparatus  for  dilatation  of  stricture  of  oesophagus. 

16.  X-ray  plate  showing  cervical  rib. 


CHAPTER  X 
THE  THORACIC  CAVITY  AND  BREAST 

The  Thorax  is  composed  of:  (1)  Twelve  ''thoracic  or 
dorsal"  vertebrae.  (2)  Twelve  pairs  of  ribs:  (a)  Six  pairs  of 
"true  ribs"  attached  directly  to  the  sternum;  (h)  four  pairs 
of  ribs  attached  by  cartilage  to  the  sternum,  and  (c)  two  pairs  of 
"floating  ribs"  which  are  unattached  at  their  anterior  ends. 
(3)  The  sternum,  or  "breast-bone."  The  contents  are:  the 
trachea  and  bronchi,  the  lungs  and  pleural  cavity,  the  great 
vessels,  the  heart  and  pericardium,  the  oesophagus,  and  medias- 
tinum. 

A.  Bony  Framework. — 1.  Vertebral  column,  (a)  Fract- 
ure with  dislocation  of  fragments  occurs  as  the  result  of  vio- 
lence involving  especially  the  spinous  process  or  part  of  the 
neural  arch.  The  effects  are  pressure  or  injury  to  the  cord. 
(See  page  111.)  Treatment:  In  selected  cases  it  is  possible  to 
expose  the  site  of  fracture  by  surgical  operation,  "laminectomy," 
and  reUeve  pressure.  (&)  Disease  of  the  vertebrae  is  practically 
limited  to  tuberculosis.  The  bodies  are  most  often  involved, 
resulting  in  characteristic  deformity,  "kyphosis,"  often  with 
"scoliosis."  Treatment:  Immobihzation  with  cast  or  appa- 
ratus. Scoliosis,  lateral  curvature  of  the  spinal  colunm  due  to 
faulty  position,  either  standing  or  sitting,  is  not  infrequent  in 
young  adults.  It  may  result  in  serious  deformity  of  the  chest 
and  impairment  of  general  health.  The  condition  calls  for 
proper  treatment:  orthopaedic  apparatus  or  gymnastic  exercise, 
and  correction  of  the  predisposing  factors. 

2.  Ribs. — Fracture  is  caused  by  compression  or  blows  on  the 
sternum :  (a)  Indirect  violence  resulting  in  a  green-stick  fracture 
at  the  point  of  greatest  curvature,  i.e.,  in  the  axillary  line.  (6) 
Direct  violence  and  depressed  fracture  associated  with  injury  to 
the  lungs  or  pleura.  Fractures  are  most  often  simple.  Evi- 
dences :  Sharp  local  pain  which  is  increased  by  coughing  or  deep 
breathing,  also  marked  local  tenderness.  Principles  of  treatment: 
Immobilization  by  tight  strapping  with  adhesive  bandage  to 
150 


THE  THORACIC  CAVITY  AND  BREAST        151 

prevent  motion  during  respiration.  To  be  efficient  it  must 
relieve  all  pain. 

3.  Sternum. — Fracture  occurs  rarely,  as  the  result  of 
crushing  injury  or  direct  "violence.  Marked  displacement  may 
cause  serious  disturbance  to  underljong  structures.  ImmobiU- 
zation  is  difficult.  Surgical  measures  may  be  necessary  to  raise 
depressed  fragments. 

Penetrating  wounds  of  the  thorax  include  gunshot  and  stab 
wounds.  These  are  often  deflected  by  bony  parts  and  remain 
superficial  instead  of  penetrating.  Wounds  which  involve  the 
great  vessels  are  usually  promptly  fatal.  In  exceptional  cases, 
certain  wounds  of  the  ventricles  or  pericardium  can  be  exposed 
surgically  and  sutured  in  time  to  save  life.  Penetrating  wounds 
of  the  lungs  are  characterized  by :  Pain,  cough,  expectoration  of 
blood.  Later  there  is  hsemothorax,  i.e.,  collection  of  blood  in 
the  pleural  cavity.  If  not  immediately  fatal,  these  collections 
are  often  absorbed  in  the  course  of  a  few  weeks  with  but 
shght  permanent  effect.  The  treatment  is  usually  expectant, 
"aspiration"  or  exploration  being  indicated  in   special  cases. 

B.  The  trachea  and  bronchi  have  been  considered  in  the 
preceding  section  (pages  146,  147).  Tumors  or  masses  in  the 
mediastinum  cause  serious  compression  of  the  trachea,  and 
disturbance  of  respiration. 

C.  The  Lungs  and  Pleural  Cavity. — Surgical  lesions  of  the 
lungs  are  rare.  Gangrene,  followed  by  lung  abscess  may  be 
caused  by:  (1)  Occlusion  of  a  bronchus.  (2)  Thrombosis  or 
embolus  in  a  branch  of  the  pulmonary  artery.  There  is  evi- 
dence of  sepsis,  and  some  local  physical  signs.  Surgical  treat- 
ment by  excision  or  drainage  is  rarely  feasible  as  the  condition 
is  usually  fatal. 

The  PLEURAL  CAVITY  (sce  Fig.  34)  on  each  side  contains  the 
lungs  and  is  lined  by  the  ''pleura,"  a  serous  membrane  composed 
of  two  layers :  (a)  Visceral  pleura,  which  is  attached  to  the  lung 
and  extends  between  the  lobes  to  the  roots  of  the  bronchi,  where 
it  is  reflected  as  (6)  the  parietal  layer,  adherent  to  the  costal 
walls  and  diaphragm.  The  pressure  within  the  pleural  cavity 
is  constantly  lower  than  that  within  the  bronchi  and  lungs, 
and  also  than  that  of  the  exterior  atmospheric  pressure. 

1.  Pneumothorax  (see  Fig.  34)  is  a  condition  where  the 
intrathoracic  or  pleural  pressure  is  equal   to   the   exterior  or 


152      ESSENTIALS  OF  SURGERY  FOR  NURSES 


atmospheric  pressure.  It  may  be :  (a)  External,  due  to  extensive 
accidental  wounds  or  operative  openings,  (h)  Internal,  due  to 
perforation  of  a  dilated  bronchus  or  lung  abscess  into  the  pleura. 
Effect:  The  increased  intrapleural  pressure  causes  collapse  of  the 
lung  on  the  side  involved  and  prevents  normal  expansion  during 
lung  inspiration.    The  lung  is  thrown  out  of  function  and  if  the 


Fig.  34. — Diagram  showing  the  pressure  relations  in  the  thoracic  or  pleural  cavity, 
and  lungs.  T,  trachea;  R.  L.  and  L.  L.,  right  and  left  lungs;  1,  bronchi  and  pulmonic 
cavity  continuous  with  the  exterior;  pressure  equal  to  atmospheric;  2,  pleural  cavity 
between;  .3,  parietal  and  4,  visceral  pleura.  Pleural  pressure  is  constantly  less  than 
pulmonic  and  atmospheric.  It  is  increased  during  expiration  and  causes  collapse  of 
the  lungs.  It  is  decreased  during  inspiration  and  allows  expansion  of  the  lung  by  the 
external  atmospheric  pressure.  Pneumothorax  is  an  artificial  communication  between 
the  pleural  space  and  the  atmospheric  pressure.  A,  external,  or  B,  internal.  Results, 
increased  pressure  in  the  pleural  cavity  and  collapse  of  the  lung. 

condition  is  bilateral,  respiration  is  impossible  unless  maintained 
by  artificial  means.  (See  Physiology.)  For  this  reason  surgical 
exploration  of  the  thorax  is  impossible  except  ^vith  special  appa- 
ratus to  maintain  the  differential  pressure.     Simple  wounds 


THE  THORACIC  CAVITY  AND  BREAST         153 

which  are  promptly  closed  cause  only  temporary  disturbance 
and  normal  pressure  relations  are  soon  re-established. 

2.  SuEGiCAL  Lesions. — (a)  Pleurisy.  Inflammation  of  the 
pleura  occurs:  (i)  Complicating  or  following  pneumonia,  (ii) 
As  an  independent  lesion.  It  may  be  ''dry/'  characterized  by 
severe  pain  in  breathing  or  coughing,  and  typical  phj^sical  signs. 
Local  treatment  consists  of  immobilization  by  tight  strapping 
with  adhesive  and  an  ice-bag. 

(6)  Pleural  effusion,  i.e.,  an  exudate  of  serous  fluid  into  the 
pleural  cavity,  may  (i)  comphcate  pleurisy;  (ii)  occur  as  a 
result  of  heart  disease  with  ''broken  compensation."  The 
effects  are:  Mechanical  interference  with  respiration,  cough, 
dyspnoea,  distress,  or  pain  which  is  increased  by  cough  and  deep 
inhalation.  There  is  sometimes  displacement  of  the  heart  and 
disturbance  in  circulation.  Characteristic  physical  signs  can 
usually  be  demonstrated. 

Principles  of  Treatment. — "Aspiration,"  i.e.,  withdrawal  of 
the  fluid  by  means  of  a  hollow  needle  introduced  between  the 
ribs  into  the  cavity,  is  commonly  done.  The  principal  danger  is, 
occasional  shock  or  syncope  from  the  sudden  aspiration  of  a 
large  amount  of  fluid.  The  procedure  is  carried  out  under 
strict  asepsis.  It  is  also  done  for  diagnosis,  i.e.,  to  determine 
the  character  of  the  fluid  present,  especially  when  suppuration 
is  suspected. 

3.  Empyema  refers  to  a  collection  of  pus  in  the  pleural  cav- 
ity, which  occurs  as  a  sequel  to  pneumonia  or  pleurisy.  The 
effects  are :    (i)  Mechanical  as  in  pleural  effusion,  and  (ii)  sepsis. 

Principles  of  Treatment. — Surgical  incision  and  drainage  are 
indicated  when  the  presence  of  suppuration  is  determined,  and 
are  obtained  by  the  resection  of  one  or  more  ribs.  In  some  cases 
antiseptic  solutions  (formalin,  in  glycerin)  are  introduced  into 
the  ca"\dty.  Persistent  after-care,  special  breathing  exercises 
are  used  to  encourage  the  expansion  of  the  contracted  lung  and 
obliteration  of  the  cavity. 

D.  The  great  vessels,  aorta,  vena-cava,  and  pulmonary 
vessels,  may  be  seriously  affected  by  pressure  of  intratho- 
racic tumors,  causing  disturbance  in  the  dependent  circulation. 
Aneurism  of  the  aorta  or  its  branches  gives  local  pressure  effects, 
pain,  local  and  referred,  and  presents  constant  danger  of  rupture 
with  fatal  hemorrhage. 


154      ESSENTIALS  OF  SURGERY  FOR  NURSES 

E.  Heart  and  Pericardium. — The  heart  presents  surgical 
lesions  only  in  case  of  certain  penetrating  wounds  involving  the 
ventricles,  which  may  be  reached  and  sutured  by  prompt  sur- 
gical incision.  The  ^pericardium  is  a  serous  cavity  surrounding 
the  heart,  similar  in  structure  to  the  pleura  and  peritoneum. 
Pericardial  effusion  or  empyema  occurs  as  a  result  of  inflammation 
and  causes  marked  disturbance  in  the  heart-beat  and  circulation. 
The  condition  is  obscure  and  recognition  is  difficult.  Aspiration 
of  pericardial  fluid  may  be  accomphshed  with  beneficial  results, 
and  the  cavity  can  be  explored  through  suitable  surgical  exposure. 

F.  The  (Esophagus  has  been  considered  on  page  148. 

G.  The  Mediastiniim  refers  to  the  space  between  the  right 
and  left  lungs  and  contains:  The  thymus  gland,  pulmonary 
lymph-nodes,  trachea  and  oesophagus,  great  vessels,  and  below, 
the  heart  and  pericardium. 

The  THYMUS  is  a  gland  of  internal  secretion,  most  active  in 
children,  and  later  atrophies.  Hypertrophy  occurs  occasionally 
in  infants,  causing  respiratory  disturbance  and  in  rare  cases, 
sudden  death.  A  Rontgen  ray  plate  will  usually  demonstrate 
the  enlarged  thymus  and  should  be  taken  in  all  cases  where 
there  is  any  suspicion.  A  few  treatments,  exposure  to  the 
X-ray  usually  gives  relief.  Enlarged  thymus  is  an  apparent 
cause  of  certain  deaths  occurring  under  surgical  ansesthesia. 
Tumors  are  rare,  but  the  pressure  effects  are  similar.  Such 
conditions  are  frequently  recognized  only  at  autopsy.  The 
pulmonary  lymph-nodes  may  undergo  enlargement  and  hyper- 
trophy secondary  to  pulmonary  infection,  or  as  an  extension 
from  adjacent  groups.  In  marked  cases  there  may  be  serious 
pressure  effects.  Surgical  treatment  is  rarely,  if  ever,  possible. 
Sepsis  in  the  mediastinum  is  usually  rapidly  fatal,  since  it  is 
inaccessible  to  surgical  relief.  It  may  be  caused  by  suppura- 
tion of  lymph-nodes,  ulceration  and  perforation  of  the  oesoph- 
agus, and  as  extension  from  the  neck. 

The  breast  or  mammary  gland  (Fig.  35)  develops  from  the 
surface  epithelium  and  is  located  in  the  subcutaneous  tissue 
under  the  skin  of  the  thorax. 

A.  The  Nipple  is  a  protrusion  of  pigmented  skin  and  re- 
ceives the  ducts  of  the  twelve  or  fifteen  lobes  of  the  breast.  The 
"areola"  is  a  pigmented  area  surrounding  the  nipple,  and  con- 
tains   numerous    sebaceous    glands    which    are    considerably 


THE  THORACIC  CAVITY  AND  BREAST        155 


hypertrophied  during  pregnancy.  Both  the  nipple  and  areola 
show  heavier  pigmentation  during  pregnancy. 

Lesions  of  the  Nipple:  (1)  Malformation.  (2)  Fissures. 
(3)  Discharge.     (4)  Malignancy. 

(1)  Malformations:  (a)  Supernumerary  nipples  with  or 
without  corresponding  breast  tissue  occur  occasionally  on  one 
or  both  sides  as  a  congenital  anomaly.  They  may  be  located 
above  the  normal  nipple  or  below  it  in  the  axilla.  Removal  is 
indicated  only  for  hypertrophy  or  tumor  formation,  (b)  De- 
formity or  retraction  of  the  nipple  may  be  congenital.    The 


APeOLAR  OR 

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Fia.  35. — Mammary  gland. 

development  of  such  a  condition,  especially  during  middle  age, 
is  suggestive  evidence  of  cancer. 

(2)  Fissures  cr  oracks  develop  from  irritation  during  nursing. 
These  are  painful,  bleed  during  nursing,  and  serve  as  a  portal 
of  entry  leading  to  breast  abscess.  Treatment  is  prophylactic: 
Care  of  the  nipples  during  pregnancy,  cleanliness  during  nursing, 
and  the  use  of  ointments  or  applications.  The  breasts  are 
pumped,  nipple  shields  used,  or  nursing  discontinued.  The 
chief  danger  is  the  development  of  breast  abscess. 

(3)  Discharge  from  the  nipple,  except  during  pregnancy  or 
lactation,  especially  a  bloody  discharge,  is  strong  evidence  of 
malignant  growth. 


156      ESSENTIALS  OF  SURGERY  FOR  NURSES 

(4)  Malignant  disease,  "Paget's  disease,"  is  a  rare  ecze- 
matous-like  condition  about  the  nipple  and  is  considered  as  an 
early  form  of  cancer. 

B.  The  Breast  is  composed  of  from  twelve  to  fifteen  gland- 
ular lobes,  each  having  a  separate  duct  leading  to  the  nipple. 
Supernumerary  masses  of  breast  tissue  are  less  frequent  than 
extra  nipples,  but  occasionally  occur  in  the  axilla.  They  are 
most  evident  during  early  lactation,  but  true  hypertrophy  or 
secretion  rarely  occurs  and  no  treatment  is  indicated. 

Surgical  lesions  include:     (1)  Infections.     (2)  Tumors. 

(1)  Infections. — Mastitis,  (a)  Acute  infection  or  abscess 
occurs  only  during  lactation,  usually  through  cracks  or  fissures 
of  the  nipple.  There  is  marked  swelling  more  or  less  limited, 
pain,  later  redness,  and  fluctuation,  with  constitutional  reac- 
tion, fever,  possibly  with  chill,  and  headache. 

Principles  of  Treatment. — Catharsis  and  measures  to  elimi- 
nate other  causes  of  persisting  fever.  Locally:  firm  bandage; 
ointments :  belladonna  or  mercury.  Massage  is  contraindicated 
since  it  is  useless  and  is  hkely  to  spread  the  infection.  An  ice- 
bag  serves  to  relieve  pain.  Surgical  incision  under  anaesthesia  is 
indicated  as  soon  as  suppuration  is  evidently  present:  (i)  To 
reheve  toxic  symptoms,  (ii)  To  alleviate  pain,  (iii)  To  pre- 
vent extension  and  unnecessary  destruction  of  tissue.  Drain- 
age must  be  adequate  since  recurrence  is  not  infrequent.  There 
is  rarely  permanent  interference  with  the  future  function  of 
the  breast. 

(b)  Chronic  breast  infection,  usually  tubercular,  bears  no 
significant  relation  to  previous  acute  infection.  The  condition 
is  rare  and  usually  secondary  to  tuberculosis  in  other  parts  of 
the  body.  There  is  gradual  development  of  a  hard,  diffuse 
swelling  of  the  breast,  with  later  enlargement  of  the  axillary 
lymph-nodes.     Malignant  disease  is  often  suspected. 

Treatment  is  surgical,  radical  removal  of  the  breast  and 
tributary  lymph-nodes,  followed  by  prolonged  constitutional 
treatment. 

(2)  Breast  tumors  include  a  variety  of  pathological  new- 
growths:  adenoma,  adeno-fibroma,  cysts,  carcinoma,  and  rarely, 
sarcoma.  Practically,  the  most  important  classification  is:  (a) 
Clinically  benign.     (5)  Doubtful,     (c)  Malignant. 

(a)  Clinically  benign  are  those  about  which  there  is  not 


THE  THORACIC  CAVITY  AND  BREAST        157 

the  slightest  doubt,  (i)  The  mass  is  definitely  circumscribed, 
but  they  may  be  multiple,  (ii)  It  is  movable  under  the  skin 
and  over  the  underlying  structures,  (iii)  Individuals  under 
thirty,     (iv)  Absolutely  no  evidence  of  malignancy. 

(&)  Doubtful  tumors  are  those  which  cannot  be  classed 
clinically  as  absolutely  benign,  but  show  no  positive  evidence 
of  mahgnancy. 

(c)  Clinically  mahgnant  tumors  occur  most  often  in  women 
over  forty  but  have  been  found  under  thirty.  Evidences  of 
malignancy  include:  (i)  Diffuse,  irregular  masses,  (ii)  Fixa- 
tion to  the  skin  or  to  underlying  structures,  (iii)  Rapid  increase 
in  size,  (iv)  Retraction  of  the  nipple,  (v)  Discharge  from  the 
nipple  other  than  that  of  lactation,  especially  a  bloody  discharge, 
(vi)  Pain,     (vii)  Enlargement  of  the  axillary  IjTiiph-nodes. 

Principles  of  Treatment. — (a)  Clinically  benign  tumors  about 
which  all  possible  question  of  mahgnancy  can  be  excluded  by  a 
competent  surgeon  may  be  treated  expectantly.  Removal  of 
the  tumor  is  indicated :  (i)  On  account  of  size  or  deformity,  and 
(ii)  to  exclude  possibihty  of  future  mahgnancy.  This  may  be 
accomplished  by  plastic  operation  with  httle  or  no  mutilation 
of  the  breast.  Multiple  tumors,  or  those  involving  both  breasts, 
are  often  left  till  after  the  child-bearing  period.  In  case  of  the 
slightest  doubt  radical  removal  of  the  breast  and  dissection  of 
the  axilla  is  indicated  without  delay. 

(6)  Doubtful  tumors  which  for  some  reason  are  not  positive- 
ly benign,  are  most  often  treated  as  mahgnant,  in  which  case 
the  prognosis  is  good.  Statistics  show  that  a  series  of  a  given 
type  of  mahgnant  growth,  removed  by  radical  operation  at  a 
stage  when  they  were  chnically  doubtful  or  benign,  resulted  in 
from  70%  to  100%  of  cures.  A  series  of  the  same  type  of 
growths  removed  by  radical  operation  after  there  was  positive 
chnical  evidence  of  malignancy,  gave  only  from  40%  to  60% 
of  cures.  We  must  remember  that  a  new-growth  in  the  breast 
which  shows  even  the  slightest  positive  sign  of  malignancy  has 
already  passed  the  early  stage  and  the  most  favorable  oppor- 
tunity for  successful  removal  with  freedom  from  recurrence  or 
metastases.  Really  early  removal  while  the  growth  is  still 
clinically  benign  or  doubtful  gives  a  favorable  prognosis,  if  done 
successfully,  with  but  httle  deformity,  mutilation,  or  loss  of 
function.    When  advised  by  a  competent  surgeon,  the  operation 


158       ESSENTIALS  OF  SURGERY  FOR  NURSES 

should  be  accepted  at  once  and  without  question,  as  delays 
are  dangerous. 

When  an  expectant  course  is  advised  it  should  be  con- 
firmed by  consultation  and  the  patient  kept  under  close  obser- 
vation Danger  signs  include:  growth  of  the  tumor,  pain, 
discharge  from  the  nipple,  changes  in  the  nipple  or  skin. 

Exploration  of  the  tumor  for  diagnosis,  by  gross  appearance 
or  frozen  section,  to  be  followed  by  proper  operation  at  the  same 
sitting,  is  sometimes  done  in  doubtful  cases,  but  is  not  a  safe 
procedure. 

Radical  operation  consists  of  amputation  of  the  breast  with 
the  pectoral  muscles  and  lymphatics  of  the  axilla,  and  a  suitable 
plastic  operation. 

(c)  Positive  evidence  of  malignancy  is  indication  for  prompt 
radical  operation,  but  gives  only  a  fair  prognosis.  Contra- 
indications: (i)  Evidence  of  metastases,  (ii)  Extensive  involve- 
ment of  the  tributary  lymph-nodes,  (iii)  Constitutional  effects, 
cachexia  or  malnutrition. 

Other  forms  of  treatment:  Radium  or  Rontgen  rays  are  of 
value,  and  indicated  (i)  following  radical  removal  to  prevent 
recurrence,  and  are  commonly  advised,  (ii)  Inoperable  growths. 
While  apparent  cure  has  been  obtained  in  certain  cases,  prompt 
radical  operation  is  indicated  in  all  but  frankly  inoperable 
cases,  since  there  is  danger  that  extensive  growth  may  occur 
while  the  patient  is  under  observation. 

DEMONSTRATIONS 

1.  Demonstration  of  the  bony  landmarks  of  the  thorax. 

2.  Various  deformities  of  the  vertebral  coluron ;  kyphosis,  lordosis,  scoliosis. 

3.  Method  of  strapping  the  chest  for  fractured  rib  or  pleurisy. 

4.  Demonstration  of  negative  thoracic  pressure  with  bottle  and  rubber  bag. 

5.  Study  of  smears  and  cultures  from  empyema. 

6.  Apparatus  and  technique  of  aspiration  of  the  plural  cavity. 

7.  Study  of  a  special  case  history  of  empyema. 

8.  Demonstration  of  apparatus  and  method  of  special  breathing  exercises 

after  empyema  damage. 

9.  An  X-ray  plate  showing  enlarged  thymus. 

10.  Demonstration  of  the  nipple  and  areola  of  pregnancy,  supernumerary- 

nipple. 

11.  Fissures  and  "cracked  nipple." 

12.  Case  of  breast  abscess  or  study  of  history  and  temperature  chi  rt. 

13.  Method  of  applying  binder  to  the  breasts. 

14.  Cases  showing  various  types  of  breast  tumor. 

15.  Special  statistics  showing  the  comparative  results  of  early  and  late 

radical  operation  for  cancer  of  the  breast. 


CHAPTER  XI 

THE  ABDOMINAL  CAVITY,  WALLS,  AND 
PERITONEUM 

The  abdominal  cavity  is  limited  above  by  the  diaphragm, 
and  below  is  continuous  with  the  "pelvic  cavity,"  to  the  levator 
ani  muscle  and  the  muscular  floor  of  the  pelvis.  The  ''true 
pelvis"  is  surrounded  by  the  sacrum  and  innominate  bones,  but 
the  cavity  is  practically  continuous  with  that  of  the  abdomen. 

The  abdominal  walls  include :  the  vertebral  column,  and  deep 
muscles  of  the  back  posteriorly.  The  upper  lateral  wall  is 
composed  of  the  lower  ribs  and  their  cartilages,  and  below  the 
lateral  muscles,  the  external  and  internal  obHque  and  trans- 
versahs  muscles  together  with  their  fascia  and  aponeurosis, 
and  the  rectus  abdominis  compose  the  lateral  and  the  anterior 
walls.  (See  Anatomy.)  These  lateral  muscles  are  continued 
forward  as  fascia  or  aponeurosis  and  pass  to  the  midhne  to  the 
"linea  alba,"  which  is  formed  by  a  fusion  of  the  fascia  from  each 
side.  The  dense  "sheath  of  the  rectus"  is  formed  by  the  apo- 
neurosis of  the  oblique  and  transversalis  muscles.  The  rectus 
muscle  extends  from  the  sternum  to  the  symphysis  pubis.  The 
anterior  wall  of  the  abdomen  is  divided  into  nine  regions  by  two 
perpendiculars  (see  Fig.  36),  "nipple"  or  "mid-clavicular" 
hnes,  and  by  transverse  lines  (a)  through  the  twelfth  ribs, 
and  (h)  through  the  crests  of  the  iliac  bones.  These  regions 
are:  the  right  and  left  hypochondriac  and  epigastric,  the  right 
and  left  lumbar  and  umbilical,  the  right  and  left  ihac,  and 
hypogastric. 

Lesions  of  the  abdominal  walls  include:  (A)  Relaxation. 
(B)  Wounds.  (C)  Hernia.  The  muscles  and  fascia  maintain  the 
intra-abdominal  pressure  and  thus  serve  indirectly  to  support 
certain  of  the  solid  organs,  liver  and  kidneys,  in  their  normal 
position.  They  are  also  important  in  respiration  and  in  certain 
functions:  vomiting,  defecation,  and  parturition. 

A.  Relaxation  of  the  walls  may  be  caused  by:  (a)  Congen- 
itally  weak  muscles;  (6)  lack  of  exercise;  (c)  wasting  disease; 

159 


160       ESSENTIALS  OF  SURGERY  FOR  NURSES 

(d)  following  rapid  or  repeated  distention  of  the  abdomen  from 
pregnancy  or  ascites.  Effects:  (a)  Lack  of  support  to  and 
"ptosis"  or  prolapse  of  abdominal  organs:  kidneys,  stomach,  or 
colon,  (6)  Constipation  and  secondary  results,  (c)  Inefficient 
expulsive  efforts  during  parturition. 

Principles  of  treatment  include:    Exercises  to  develop  the 
muscles,  general  tonics,  special  supports  and  corsets.    Surgical 

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operations  to  correct  the  position  of  displaced  organs  are  indi- 
cated in  selected  cases,  but  recurrence  of  the  condition  is  not 
infrequent. 

B.  Wounds  of  the  abdominal  wall  may  be  (1)  accidental, 
and  (2)  operative. 

(l)  Accidental  Wounds. — (a)  Crushing  injury  may  cause: 
(i)  Rupture  of  abdominal  muscles  and  subsequent  hernia,  (ii) 
Hemorrhage  into  the  tissues,  hsematoma,  and  possibly  sepsis, 
(iii)  Injury  to  soUd  organs  (liver,  spleen,  or  kidneys),  with  se- 


THE  ABDOMINAL  CAVITY  161 

rioUs  intra-abdominal,  concealed  hemorrhage,  which  may  be 
fatal,  (iv)  Rupture  of  hollow  organs  (stomach  or  bladder), 
especially  if  they  are  distended.  Surgical  measures  are  indicated 
in  certain  cases. 

(6)  Penetrating  wounds,  stab  or  gunshot,  result  in  slight 
injury  to  the  abdominal  wall  which,  in  itself,  is  not  serious.  The 
most  significant  effect  is  peritonitis,  which  is  not  infrequently 
fatal.  (See  page  168.)  This  may  be  caused  by:  (i)  Contami- 
nation from  the  skin  or  surface;  (ii)  penetration  of  the  intes- 
tinal tract  or  bladder,  or  (iii)  infection  of  a  hsematoma  from 
intra-abdominal  bleeding. 

Indications  for  Treatment. — (l)  When  aseptic  surgical  care 
is  accessible,  immediate  laparotomy  is  usually  indicated,  with 
repair  of  perforation,  control  of  bleeding,  and  provision  for 
drainage.  Delay  of  more  than  a  few  hours  renders  the  prog- 
nosis much  more  grave,  and  in  many  of  the  late  cases  expectant 
treatment  is  preferable,  since  extensive  procedures  add  to  the 
shock  and  spread  the  infection.  When  localized  abscesses 
develop,  these  may  be  opened  and  drained. 

(2)  An  elective  operative  wound  of  the  abdomen,  laparotomy, 
is  made  to  gain  access  to  the  peritoneal  cavity  or  intra-abdom- 
inal structures.  There  are  a  great  number  of  types  of  incisions, 
each  adapted  for  special  purposes,  or  selected  at  the  discretion 
of  the  surgeon.  All  involve :  (a)  Incision  through  the  skin  and 
subcutaneous  fat.  (6)  Division  of  the  deep  fascia,  sheath  of 
the  rectus  muscle,  or  aponeurosis  of  the  external  oblique,  (c) 
All  incisions  except  those  through  the  linea  alba  require  dis- 
placement or  separation  of  muscle  fibres,  and  some  include  a 
transverse  division  of  muscles,  (d)  Incision  of  the  parietal 
peritoneum,  in  addition  to  the  special  intra-abdominal  pro- 
cedures in  a  given  case.  To  secure  firm  union  and  a  solid  ab- 
dominal wall,  there  must  be:  (l)  Absolute  asepsis  and  clean 
wound  healing.  (2)  Accurate  apposition  by  suture  of  each 
layer:  (i)  Peritoneum,  (ii)  muscle,  (iii)  deep  fascia,  (iv) 
subcutaneous  fat,  and  (v)  skin. 

This  accurate  union  of  the  divided  layers  may  be  prevented 
by:  (a)  Infection  or  breaking  down  of  the  wound,  (h)  Drain- 
age through  the  wound  when  this  is  indicated  for  septic  condi- 
tions within  the  peritoneum.  In  favorable  cases,  when  drainage 
is  maintained  for  only  a  few  days,  most  of  the  wound  is  protected 
11 


162      ESSENTIALS  OF  SURGERY  FOR  NURSES 

and  heals  properly  with  a  firm  scar.  In  unfavorable  cases,  cer- 
tain layers  fail  to  unite  completely  as  a  result  of  sepsis  or  incom- 
plete union  and  subsequent  tension.  The  result  is  a  weakening 
of  the  scar  and  the  development  of  a  "post-operative  hernia." 

C.  Hernia  or  "rupture"  is  a  protrusion  of  abdominal  con- 
tents through  the  walls  of  a  cavity  (abdomen),  forming  a 
prominent  sweUing  under  the  skin  and  subcutaneous  tissue. 
Types:  (1)  Post-operative  hernia  through  a  weakened  or  in- 
completely healed  abdominal  wound.  (2)  Hernia  through  one 
of  the  normal  potential  openings  of  the  abdomen:  (a)  umbili- 
cus, (b)  inguinal  canal,  (c)  femoral  canal. 

In  all  types  of  hernia,  we  have  to  consider:  (1)  The  ring  or 
neck  which  is  formed  by  the  opening  of  the  canal  or  the  muscle 
and  layers  of  fascia  surrounding  the  rupture  in  a  post-operative 
hernia.  (2)  The  coverings  of  the  hernia  include  the  skin,  sub- 
cutaneous tissue,  and  one  or  more  layers  of  fascia.  (3)  The 
sac,  composed  of  peritoneum  and  continuous  with  peritoneal 
lining  of  the  abdomen.  (4)  The  contents,  which  may  be :  Peri- 
toneal fluid,  omentum,  intestine,  bladder,  or  rarely,  the  tube 
or  ovary. 

Evidence  of  Hernia. — A  swelling  or  tumor  about  the  um- 
bilicus, an  operative  wound,  in  the  groin,  labia  majora,  or  scrotum. 
This  may  be  present  only  after  exertion,  or  be  constant.  It  is 
increased  by  straining,  and  transmits  a  characteristic  impulse  on 
coughing.  The  contents  can  usually  be  reduced  by  careful 
manipulation,  and  a  definite  opening  can  be  demonstrated  on 
examination.  The  patient  complains  of  the  swelling,  a  sense  of 
drawing  or  weakness  in  the  region,  and  there  may  be  more  or 
less  gastro-intestinal  disturbance  from  peritoneal  irritation  in 
some  cases.  The  course  of  development  is  usually  a  progressive 
increase  in  the  extent  of  the  swelling  and  size  of  the  opening. 
The  peritoneal  sac  forms  in  the  initial  stage  of  the  process  and 
its  presence  in  the  hernia  prevents  any  tendency  to  spontarieous 
closing  of  the  canal  or  neck.  Any  increase  of  intra-abdominal 
pressure  (straining,  coughing,  or  exertion)  tends  to  further 
distend  the  sac  and  increase  the  size  of  the  hernia.  Reducible 
hernias  are  those  whose  contents  can  be  reduced,  i.e.,  by  means 
of  gentle  manipulation,  forced  through  the  opening  into  the 
abdominal  cavity. 

Complications  of  hernia  are:  (1)  Incarceration  of  the  con- 


THE  ABDOMINAL  CAVITY  163 

tents,  caused  by  adhesions  to  the  walls  of  the  sac,  or  constric- 
tion of  the  neck  or  ring  so  that  the  hernia  can  no  longer  be  re- 
duced by  manipulation.  This  condition  is  a  contraindication 
to  the  use  of  a  "truss,"  since  there  is  danger  of  irritation  of  the 
contents  and  injury,  and  spontaneous  closing  of  the  ring  or  neck 
of  the  hernia  is  no  longer  possible. 

(2)  Strangulation  of  hernial  contents,  i.e.,  interference  with 
the  blood  supply  of  structures  in  the,  hernial  sac,  may  be  due  to 
constriction  of  the  neck  of  the  rupture,  or  to  torsion  and  con- 
striction of  the  protruding  parts.  Gangrene  of  the  structure 
and  peritonitis  follow  within  a  short  time,  forty-eight  hours  to  a 
few  days. 

(3)  Intestinal  obstruction  is  usually  associated  with  strangu- 
lation of  a  portion  of  the  intestine  in  a  hernial  sac,  either  as  a 
cause  or  an  effect.  This  condition  presents  a  serious  emergency 
(see  page  189)  and  is  fatal  unless  relieved  within  a  few  hours. 

Principles  of  Treatment. — (l)  Palliative.  Umbilical  and 
inguinal  hernia  in  infants  can  be  retained  and  often  cured  by  a 
suitable  support.  In  older  indi\'iduals  simple  hernias,  inguinal 
or  femoral,  can  usually  be  retained  by  means  of  a  "truss."' 
Symptoms  are  reheved  and  further  increase  is  prevented,  but 
cure  is  not  often  to  be  expected.  The  presence  of  an  incarcerated 
hernia  contraindicates  the  use  of  a  truss,  since  it  is  no  longer 
possible  to  retain  the  abdominal  contents  and  there  is  danger  of 
injury  from  the  truss. 

(2)  Operative  treatment  is  indicated  as  an  emergency 
procedure  in  strangulation  or  intestinal  obstruction.  Incarcer- 
ated hernia  is  a  positive  indication  for  operative  measures: 
(a)  Since  this  presents  the  only  hope  of  a  cure;  (6)  no  truss  or 
support  can  retain  the  contents  and  there  is  a  progressive  in- 
crease in  size,  and  (c)  there  is  a  constant  danger  of  strangu- 
lation or  intestinal  obstruction.  Simple  hernias  in  older 
children  or  adults  can  be  cured  only  by  operation.  This  is 
indicated:  to  relieve  symptoms  and  incapacity  for  work,  to 
prevent  increase  in  size,  and  to  remove  the  danger  of  serious 
complication.  It  is  commonly  advised  for  all  individuals  unless 
there  is  a  definite  contraindication  to  a  comparatively  simple 
operation,  which  is  often  done  under  local  anesthesia.  The 
following  steps  are  involved:  (i)  Incision  and  exposure  of 
the  peritoneal  layer,     (ii)  Dissection  of  the  sac  to  the  level 


164       ESSENTIALS  OF  SURGERY  FOR  NURSES 

of  the  peritoneum,  (iii)  Opening  the  sac  and  reduction  or  ex- 
cision of  the  contents,  as  may  be  indicated,  (iv)  Ligation  of 
the  neck,  excision  of  the  sac,  and  closure  of  the  peritoneum. 
(v)  Overlapping  and  accurate  closure  of  the  muscles  and  fascia 
forming  the  hernial  opening. 

Special  characteristics  of  various  forms  of  hernia: 

(1)  PosT-OPEKATivE  hernia  occurs  at  the  site  of  a  former 
abdominal  wound  where  union  of  the  various  layers  is  incom- 
plete, or  subsequent  separation  has  taken  place.  The  sweUing 
is  diffuse  and  the  neck  is  rather  large.  Incarceration  is  common, 
but  strangulation  rarely  occurs.  The  contents  include:  (a) 
Omentum,  which  is  often  adherent  and  has  to  be  excised;  (b) 
intestine,  which  is  also  often  adherent  and  likely  to  be  injured 
at  operation.  Suitable  supports  give  comfort  and  may  relieve 
symptoms,  though  the  patient  is  incapacitated  for  active  work, 
and  the  condition  tends  to  increase.  Surgical  repair  offers  the 
only  hope  of  cure  and  is  commonly  advised  as  early  as  possible 
unless  there  is  some  definite  contraindication.  The  procedure 
presents  greater  risks  than  does  the  operation  for  other  types  of 
hernia,  and  recurrence  is  also  more  frequent. 

(2)  Hernia  through  normal  openings  or  canals:  (a)  The 
Umbilicus.  During  embryonic  life  there  is  a  definite  opening  in 
the  abdominal  wall  through  which  the  umbilical  vessels  pass, 
and  at  one  stage  of  development  there  is  a  diverticulum  from 
the  intestinal  tract  (Meckel's  diverticulum)  extending  into  the 
umbilical  cord.  The  opening  normally  closes  at  birth,  leaving  a 
firm  resistant  wall.  Umbilical  hernia  occurs  most  often  in  the 
new-born  or  during  early  infancy  as  a  result  of  incomplete  closure 
of  the  opening.  Treatment  consists  of  reduction  of  the  hernia 
and  tight  strapping  across  the  umbilicus  with  adhesive  plaster. 
Cure  usually  results  within  a  few  weeks  if  the  hernia  can  be  re- 
duced and  retained.  Serious  complications  are  rare.  In  ex- 
ceptional instances  a  large  hernia  occurs,  to  a  degree  that  a 
considerable  portion  of  the  abdominal  organs  are  contained  in 
the  umbilical  hernial  sac.  For  these  extreme  cases  operation 
is  necessary,  though  occasionally  is  unsuccessful. 

Umbilical  hernia,  or  some  form  of  "ventral  hernia,"  occurs 
occasionally  in  the  adult,  caused  by:  (i)  Defect  in  the  sheath 
of  the  rectus  muscle  especially  about  the  umbilicus,  (ii)  Sep- 
aration of  the  rectus  muscles.    These  hernise  may  reach  tremen- 


THE  ABDOMINAL  CAVITY  165 

dous  size  and  present  the  same  complications  and  considera- 
tions for  treatment  as  does  post-operative  hernia. 

Inguinal  hernia  occurs  through  the  inguinal  canal,  most 
often  in  the  male  and  only  rarely  in  the  female.  The  inguinal 
canal  is  an  obhque  space  through  the  abdominal  wall  containing 
the  vessels  and  ducts  of  the  testes  in  the  male  (and  the 
round  ligament  of  the  uterus  in  the  female) ,  and  passing  from 
the  abdominal  cavity  to  the  testes  (or  the  labium  majora).  The 
canal  is  a  more  definite  space  in  the  male,  which  fact  explains  the 
greater  frequency  of  inguinal  hernia  in  boys  and  men.  The  condi- 
tion may  occur:  In  babies  as  a  result  of  congenital  defect,  when  it 
is  usually  reducible  and  often  cured  by  a  proper  truss,  though 
some  cases  recur  later.  In  the  adult  the  causes  are:  (i)  Re- 
currence or  persistence  of  congenital  hernia,  (ii)  Weak  muscles 
and  undue  strain,  especially  if  continued  or  repeated.  Compli- 
cations are:  Incarceration,  strangulation,  and  intestinal  ob- 
struction, which  demand  suitable  surgical  rehef.  In  simple  cases 
operation  is  elective  but  offers  the  only  means  of  cure. 

(c)  Femoral  hernia  occurs  through  the  "femoral  ring"  or 
canal,  a  passage  under  Poupart's  ligament  (see  Anatomy)  to 
the  inner  side  of  the  femoral  vessels.  The  canal  is  normally 
filled  with  fat  and  lymph-nodes,  but  a  hernia  occasionally  de- 
scends through  it  to  the  inner  side  of  the  thigh,  not  into  the 
scrotum  or  labium  majora,  as  is  the  case  with  inguinal  hernia. 
This  type  occurs  more  often  in  the  female.  Incarceration  and 
strangulation  are  frequent  comphcations.  Suitable  trusses 
may  protect  the  opening  and  prevent  the  descent  of  abdominal 
contents  but  have  no  curative  effect  on  the  hernial  opening. 
Operative  treatment  is  urgently  indicated  in  complicated  cases 
and  is  the  procedure  of  choice  in  all,  since  it  is  the  only  means 
of  cure. 

THE  PERITONEAL  CAVITY 

This  comprises  the  entire  abdominal  cavity  which  is  lined 
with  the  serous  "parietal  peritoneum"  similar  in  structure 
to  the  pleura  and  pericardium.  The  various  abdominal  organs — 
gastro-intestinal  tract,  liver,  spleen,  kidneys,  bladder,  and 
female  genital  organs — develop  from  the  posterior  abdominal 
wall  and  project  to  a  greater  or  less  extent  into  the  cavity. 
They  are  thus  covered  to  a  corresponding  degree  by  a  "visceral 
layer"  of  the    peritoneum.    The  peritoneal  cavity  is  a  closed 


166       ESSENTIALS  OF  SURGERY  FOR  NURSES 


space,  except  that  in  the  female  the  fallopian  tubes  open  di- 
rectly into  the  cavity,  thus  giving  an  indirect  communication 
through  the  tubes,  uterus,  and  vagina  to  the  exterior.  It  will 
be  seen  later  that  this  communication  serves  as  an  important 
portal  of  entry  for  infection  and  pelvic  peritonitis. 

The  Mesenteries  (Fig.  37)  represent  folds  of  the  perito- 
neum formed  by  the  growth  of  certain  organs :  gastro-intestinal 
tract  and  uterus,  which  come  to  lie  freely  in  the  cavity,  being 
attached  to  the  posterior  wall  by  the  reflection  of  peritoneum 


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Fig.   37. — Relations  of  gastro-intestinal  tract  to  the  peritoneal  cavity. 

or  mesentery.  Between  the  layers  of  the  mesentery,  the  blood 
and  lymph-vessels  and  nerve  supply  pass  from  the  posterior 
wall.  The  Great  Omentum  represents  a  fold  of  the  mesentery  of 
the  stomach  which  develops  and  extends  downward  in  front  of 
the  small  intestines  just  inside  of  the  abdominal  wall.  The 
omentum  contains  considerable  deposits  of  fat,  has  a  rich  vas- 
cular supply,  and  normally  hangs  freely  in  the  abdominal  cav- 
ity. In  case  of  local  inflammatory  changes  in  the  peritoneum, 
the  omentum  becomes  adherent  and  plays  an  important  part  in 
the  "walling-off  "  process. 

The   peritoneal   cavity  normally  contains   a   considerable 


THE  ABDOMINAL  CAVITY  167 

amount  of  clear  serous  fluid  which  prevents  friction  and  allows 
free  movement  of  the  surfaces. 

Ascites  refers  to  an  increase  in  the  amount  of  peritoneal 
fluid  and  occurs  as  a  result  of:  (a)  Mechanical  disturbances  in 
the  portal  circulation,  as  cirrhosis  of  the  liver.  (6)  Lesions  of  the 
general  circulation,  broken  compensation,  due  to  heart  or 
kidney  disease,  (c)  Irritation  or  inflammation  of  the  perito- 
neum, when  the  fluid  soon  becomes  purulent.  (See  Peritonitis, 
page  168).  (d)  Certain  mahgnant  tumors  extending  into  the 
peritoneum.  Ascites  is  an  important  cUnical  condition,  often 
independent  of  inflammation.  It  develops  gradually,  often  with 
marked  enlargement  of  the  abdomen,  and  the  amount  of  fluid 
may  reach  several  quarts  or  gallons.  The  effects  are  mechanical 
pain,  gastro-intestinal  disturbance,  interference  with  move- 
ments of  the  diaphragm,  and  consequent  respiratory  embar- 
rassment. The  characteristic  physical  sign  of  "movable  dull- 
ness" on  percussion  can  usually  be  demonstrated. 

Principles  of  Treatment. — (a)  Measures  to  influence  the 
underlying  cause:  heart,  kidney,  or  hver.  (6)  Withdrawal  of 
the  fluid  by  aseptic  puncture  with  a  trocar.  This  gives  marked 
rehef,  but  reaccumulation  frequently  occurs  with  surprising 
rapidity,  especially  in  cases  due  to  cirrhosis  of  the  liver.  The 
procedure  is  often  repeated  at  frequent  intervals  with  no  harm- 
ful effect.  There  is  danger  of  shock  and  serious  reaction  when  a 
large  amount  of  fluid  is  rapidly  withdrawal.  Also  injury  to 
viscera,  and  peritonitis,  (c)  Operative  procedures  which  aim  to 
provide  a  permanent  outlet  for  the  accumulating  fluid  are 
sometimes  reconunended  for  special  cases. 

Peritonitis. — Inflammation  involving  the  peritoneum  may 
be:  (1)  Acute,  either  local  or  general  and  diffuse.  (2)  Chronic, 
usually  tubercular,  and  diffuse. 

( 1)  Acute  Peritonitis  . — Bacteria  may  reach  the  peritoneum 
and  cause  infection :  (a)  Through  penetrating  wounds  from  the 
exterior,  either  accidental  or  operative.  (6)  Contamination 
from  gastro-intestinal  tract,  which  is  always  infected,  occurs: 
(i)  By  accidental  wounds  which  penetrate  the  wall  of  the  stom- 
ach or  intestine,  (ii)  Operative  procedures  by  which  contents 
of  the  tract  reach  the  peritoneum,  (iii)  Perforation  or  rupture 
of  ulcerations  of  the  tract :  Gastric  or  duodenal  ulcer,  typhoid 
ulcer  of  the  small  intestine,  gangrenous  appendicitis,  ulceration 


168       ESSENTIALS  OF  SURGERY  FOR  NURSES 

or  diverticulitis  of  the  colon,  (c)  Acute  cholecystitis  may  gradu- 
ally extend  to  the  surrounding  peritoneum,  or  sudden  rupture  of 
a  distended  gangrenous  gall-bladder  occasionally  gives  rise  to  a 
diffuse  peritonitis,  (d)  Abscess  or  suppuration  of  the  pancreas 
is  a  rare  cause  of  an  extremely  severe  type  of  general  peritonitis, 
(e)  The  genital  tract  in  the  female,  including  the  uterus  and 
fallopian  tubes,  when  involved  in  acute  inflammatory  processes 
(gonorrheal  or  puerperal),  are  Ukely  to  be  complicated  by  pelvic 
or  general  peritonitis.  This  may  occur  either  by  direct  exten- 
sion along  the  tubes  or  through  the  walls  of  the  structures  and 
surrounding  tissues.  (/)  Perforation  or  injury  to  the  urinary 
bladder  is  a  less  frequent  cause  of  general  peritonitis,  (g)  Rare 
causes  are:  rupture  of  the  spleen,  suppurating  lymph-nodes,  or 
retro-peritoneal  abscess. 

Course  and  Effects. — General  or  diffuse  peritonitis  results  at 
the  outset:  (a)  When  a  large  amount  of  septic  material  sud- 
denly reaches  the  free  peritoneal  cavity.  Example :  Rupture 
of  a  gastric  ulcer  or  gangrenous  appendix,  gall-bladder,  or 
certain  penetrating  wounds.  (6)  Sudden  extension  from  a 
localized  process  due  to  rupture  or  surgical  interference.  The 
onset  is  sudden,  in  some  cases  with  little  definite  warning.  There 
are  severe  abdominal  pain,  high  fever  and  toxaemia,  rapid  pulse, 
vomiting,  marked  distention  of  the  abdomen  and  rigidity  of 
the  abdominal  muscles.  Later  there  is  paralysis  of  the  intesti- 
nal tract,  more  distention,  and  intestinal  obstruction.  The 
condition  is  usually  fatalunless  efficient  treatment  can  be  given 
within  a  few  hours. 

Localized  or  circumscribed  peritonitis  results  when  the 
contamination  occurs  more  gradually  about  a  wound,  or  as  an 
extension  from  ulcer  of  the  stomach,  appendix  or  other  regions. 
It  is  often  caused  by  organisms  of  relatively  low  virulence,  though 
there  may  be  marked  constitutional  reaction  in  such  a  manner 
that  protective  adhesions  form,  between  neighboring  layers  of 
peritoneum  and  omentum,  which  tend  to  wall  off  and  limit  the 
process.  The  favorable  course  in  such  a  case  consists  of  the 
development  of  a  dense  mass  of  adhesions  and  limitation  of  the 
infection  to  a  circumscribed  area  (peri-appendix  abscess,  or 
pelvic  peritonitis)  and  destruction  of  the  organisms  so  that  the 
contents  may  become  sterile.  There  is  constant  danger  that  such 
protective  adhesions  will  not  limit  the  infection,  or  that  they 


THE  ABDOMINAL  CAVITY  169 

may  be  broken  down  by  active  peristalsis  (from  catharsis)  or 
manipulation  at  operation,  and  a  rapidly  progressive  perito- 
nitis result. 

Evidences  of  local  peritonitis  are  much  the  same  as  those  of 
an  early  diffuse  process :  Abdominal  pain,  more  locahzed,  also 
tenderness  and  muscular  rigidity,  digestive  disturbances,  nausea 
and  vomiting,  abdominal  distention,  and  constitutional  evi- 
dences of  infection  and  toxsemia.  There  is  often  history  of  pre- 
ceding gastro-intestinal  disturbance,  depending  on  the  cause 
in  any  given  case.  The  greatest  danger  is  that  the  process  be 
mistaken  for  a  simple  gastro-intestinal  upset  from  indigestion 
and  treated  by  catharsis,  thereby  stimulating  active  peristalsis 
and  interfering  with  nature's  attempts  to  locahze  the  process. 

Principles  of  Treatment. — The  most  prominent  symptoms, 
severe  abdominal  pain,  distention,  and  vomiting,  are  caused  by 
peritoneal  irritation,  and  are  often  mistakenly  considered  as 
due  to  acute  indigestion  or  constipation.  If  the  condition  is  not 
masked  by  morphine,  recognition  of  a  serious  surgical  lesion  is 
soon  possible;  therefore  hypnotics  are  to  be  used  with  the  greatest 
care,  and  then  only  on  the  direct  order  of  the  surgeon  in  charge. 
Pain  is  an  important  indication  of  the  severity  of  the  condition. 
It  is  a  cry  for  help,  and  in  most  cases  morphine  or  hypnotics 
muffle  the  cry  but  do  not  supply  the  help.  Cathartics  and 
fluids  by  mouth  stimulate  intestinal  peristalsis,  thereby  in- 
creasing the  pain  and  interfering  with  the  walling-off  process 
by  protective  adhesions.  The  indication  is  to  withhold  cathar- 
tics, food,  and  fluids  by  mouth  till  the  surgeon  can  exclude  the 
presence  of  a  serious  surgical  lesion,  not  only  peritonitis  but 
inflammatory  conditions  which  are  likely  to  extend  to  the 
peritoneum,  or  intestinal  obstruction.  (See  page  180.)  Vom- 
iting is  controlled  by  gastric  lavage  in  certain  cases.  Abdom- 
inal pain  is  reheved  by  an  ice-bag  and,  possibly,  carefully  di- 
rected doses  of  morphine.  Fluids  are  supplied  by  proctoclysis, 
repeated  at  regular  intervals,  also  by  hypodermoclysis.  When 
indicated,  the  bowels  may  be  moved  by  enema,  and  catharsis 
by  mouth  is  dispensed  with  till  the  condition  is  clear.  For  the 
sepsis  and  toxsemia,  suitable  constitutional  measures  are  used. 
Such  palhative  means  are  indicated:  (a)  In  early  cases  till  a 
diagnosis  is  made  and  decision  reached  regarding  operative 
treatment.     (6)  As  an  elective  procedure  in  certain  patients 


170       ESSENTIALS  OF  SURGERY  FOR  NURSES 

seen  late  after  localization  is  taking  place,  (c)  Post-operative. 
In  some  such  cases  operative  manipulation  tends  to  spread  the 
process,  and  is  best  delayed  till  localization  is  complete  and  the 
resulting  abscess  is  later  opened  and  drained.  As  a  rule,  prompt 
surgical  treatment  presents  the  only  means  of  controlling  the 
condition,  and  unless  this  is  successfully  accomplished  within  the 
first  few  hours,  the  prognosis  becomes  rapidly  worse  or  hopeless, 
especially  in  cases  of  general,  diffuse  peritonitis. 

Surgical  treatment  has  two  aims:  (a)  To  provide  adequate 
drainage  of  the  infected  cavity.  This  may  include  simply  a 
local  area,  i.e.,  a  walled-off  peri-appendiceal  abscess,  or  general 
diffuse  processes  including  the  entire  cavity.  In  such  cases  it  is 
necessary  that  all  pockets  or  localizations  be  reached  and  drained. 
This  is  usually  accomplished  by  rubber  tubes  which  reach  the 
bottom  of  special  abscess  cavities,  and  also  certain  regions  where 
localization  is  more  common,  i.e.,  the  pelvis  or  renal  fossa. 
The  drainage  tubes  are  brought  to  the  surface  in  the  laparotomy 
wound,  through  special  stab-wounds  at  dependent  regions,  or 
through  the  vagina,  and  are  left  in  place  till  the  discharge  has 
ceased  and  the  condition  is  under  control. 

Special  after-treatment  is  necessary:  postures  (example, 
"Fowler's  position,"  i.e.,  imitating  the  sitting  posture,  which 
secures  localization  of  purulent  material  in  the  pelvis  where 
drainage  is  better  and  there  is  less  absorption  of  toxines).  Con- 
stitutional measures  to  overcome  infection  and  secure  the 
elimination  of  toxines  are  of  great  value  and  importance.  Op- 
erations to  remove  the  causal  lesions  are  possible  in  suitable 
cases  but  are  often  delayed  until  the  acute  stage  has  passed 
and  the  patient  is  in  condition  to  stand  extensive  procedures. 
Example:  Removal  of  gangrenous  appendix,  inaccessible  to 
the  wound.  Closure  of  a  ruptured  gastric  ulcer  is  usually  ac- 
complished at  the  original  operation. 

(2)  Chronic  or  tubercular  peritonitis  occurs  at  any  age 
and  is  usually  secondary  to  other  tubercular  lesions,  though 
these  may  be  inactive.  It  is  part  of  a  constitutional  disease 
and  the  local  process  is  insidious  in  its  onset.  The  infection 
reaches  the  peritoneum  through  lesions  of  the  appendix,  fallo- 
pian tube,  or  intestinal  tract.  Changes  consist  of:  (a)  Ascites; 
(6)  characteristic  tubercles  on  the  visceral  and  parietal  layers 
of  the  peritoneum;  (c)  localized  abscesses  walled  off  by  dense 


THE  ABDOMINAL  CAVITY  171 

adhesions,  and  (d)  in  later  stages  of  the  disease  there  may  be 
large  masses  of  inflammatory  tissue  causing  stricture  or  defor- 
mity of  the  intestinal  tract.  Evidences  of  the  processes  are: 
(a)  Constitutional  symptoms  and  signs  of  the  disease:  irregular 
temperature,  night-sweats,  loss  of  weight,  and  malaise,  (b) 
Local:  Increase  in  size  of  the  abdomen,  pain,  evidence  of  movable 
dulness,  free  peritoneal  fluid,  digestive  disturbance,  masses  in 
the  abdomen. 

Principles  of  Treatment. — (a)  Constitutional  and  specific 
therapy  as  for  other  forms  of  tuberculosis. 

(6)  Local  surgical  measures  aim  to :  (i)  Eradicate  the  portal 
of  entry  or  local  lesion  (appendix  or  fallopian  tube),  (ii)  To 
evacuate  suppurating  areas,  excess  fluid,  or  remove  masses 
which  interfere  with  the  function  of  the  intestinal  tract.  Drain- 
age is  rarely  used  in  these  cases  on  account  of  the  danger  of 
persistent  fistulae  breaking  through  into  the  intestinal  tract. 

The  prognosis  in  fairly  early  cases  is  good,  but  constitu- 
tional treatment  must  be  continued  for  months  or  years,  as  in 
other  forms  of  tuberculosis.  Recurrence  is  frequent  and  a  case 
can  be  considered  as  cured  only  after  a  period  of  about  three 
years  of  good  health. 

DEMONSTRATIONS 

1.  Demonstration  of  the  abdominal  cavity  and  walls,  also  divisions  on 

anatomical  chart. 

2.  Demonstration  of  posture  and  form  of  the  abdomen  in  cases  of  marked 

ptosis,  styles  of  binders  and  supports  and  exercises. 

3.  Cases  showing  types  of  hernia,  histories  of  cases  with  compUcations  and 

operative  results. 

4.  AppUcation  of  "skein  truss"  in  children,  and  strapping  for  mnbiUcal 

hernia  in  infants,  appHcation  of  truss  in  adults. 

5.  Demonstration  of  the  various  canals  on  anatomical  chart. 

6.  Styles  of  "trusses"  and  appHcation. 

7.  Demonstration  of:     the  mesentery,  omentum,  and  serous  layers  on 

anatomical  chart  or  laboratory  animal. 

8.  Case  histories  of  general  peritonitis  following  various  abdominal  lesions. 

9.  Apparatus  and  method  of  abdominal  paracentesis. 

10.  Demonstration  and  methods  of  post-operative  treatment  of  general 

peritonitis. 

11.  Case  histories  of  tubercular  peritonitis. 


CHAPTER  XII 

THE  GASTRO-INTESTINAL  ORGANS 

These  include :  The  gastro-intestinal  tract  proper :  stomach, 
small  intestine,  large  intestine,  colon,  rectum,  anus,  and  ap- 
pendix; the  accessory  organs:  liver,  bile  passages,  pancreas, 
and  spleen. 

GASTRO-INTESTINAL  DISTURBANCES 

(l)  Acute  indigestion,  characterized  by  abdominal 
pain,  local  tenderness,  nausea,  vomiting,  abdominal  distention 
and  distress,  results  from  a  variety  of  conditions,  and  may  be 
an  important  indication  of  serious  surgical  lesions.  Causes:  (a) 
Irritating  substances  in  the  tract,  (i)  Poisons:  Arsenic,  mer- 
cury, or  ''ptomaines"  which  set  up  a  sharp  reaction  with  pain, 
vomiting,  and  diarrhoea,  representing  an  attempt  to  empty  the 
tract,  but  is  not  associated  with  fever,  (ii)  Acute  indigestion 
from  improper  foods,  drinks,  or  constipation  may  cause  pain, 
nausea,  vomiting,  or  diarrhoea,  but  no  fever,  or  marked  local 
tenderness.  (6)  Obstruction  of  the  bowels  causes  severe  general 
abdominal  pain  and  distention,  persistent  vomiting  which 
finally  becomes  fecal,  and  marked  prostration,  (c)  Inflam- 
matory lesions  of  the  appendix  or  gall-bladder  are  associated 
with  localized  pain,  tenderness,  muscle  rigidity  protecting 
underlying  structures,  with  fever  and  sepsis,  as  well  as  digestive 
disturbances,    (d)  Peritonitis  from  any  cause. 

The  important  considerations  in  this  connection  are: 

(a)  That  the  most  prominent  s5Tiiptoms,  pain,  nausea,  and 
vomiting,  may  be  caused  either  by  simple  irritations  which  clear 
up  when  the  causes  are  removed  by  vomiting  or  catharsis;  or 
by  serious  inflammatory  lesions  for  which  surgical  measures 
are  urgently  indicated. 

(6)  The  severity  and  persistence  of  the  symptoms  serve  to 
indicate  the  nature  of  the  cause,  and  should  not  be  masked  by 
morphine  or  hypnotics. 

(c)  In  any  case  food  or  fluids  by  mouth  increase  the  irri- 
tation and  peristalsis,  therefore  should  be  withheld  till  the 
condition  is  controlled. 
172 


THE  GASTRO-INTESTINAL  ORGANS  173 

{d)  Cathartics  stimulate  peristalsis,  often  increase  the  pain 
and  vomiting,  and  are  a  positive  danger  in  case  of  organic  or 
inflammatory  lesions.  Therefore  they  are  best  withheld  till 
the  nature  of  the  condition  has  been  determined. 

(e)  Serious  comphcations,  or  a  fatal  outcome,  are  often 
caused  by  mistaking  the  early  stage  of  an  inflammatory  lesion 
(appendicitis)  for  a  simple  indigestion,  and  giving  improper 
treatment  (cathartics),  or  masking  the  symptoms  and  signs  by 
morphine.  Persistent  vomiting,  definite  locahzed  pain,  ten- 
derness, or  muscle  rigidity,  fever,  leucocytosis,  or  evidence  of 
sepsis,  indicate  a  serious  lesion  of  the  intestinal  tract,  and 
threatened  peritonitis. 

(2)  CimoNic  INDIGESTION  includes:  Persistent  or  recurrent 
gastro-intestinal  disturbance,  pain  in  relation  to  food,  attacks  of 
nausea  and  vomiting,  constipation  or  diarrhoea. 

Causes. — (a)  Constitutional  diseases,  nephritis,  diabetes, 
anemia,  "Grave's  disease,"  cardiac  lesions.  (6)  Chronic  in- 
toxications: lead,  alcohol,  or  tobacco,  (c)  Nervous  conditions : 
improper  diet,  lack  of  exercise,  constipation,  (d)  Organic  dis- 
ease, surgical  lesions:  gastric  or  duodenal  ulcer,  cholecystitis, 
chronic  appendicitis,  tuberculous  peritonitis,  mahgnant  disease, 
or  lesions  of  the  female  genital  tract. 

Considerations. — (a)  Chronic  indigestion  or  recurrent  attacks 
of  pain,  nausea  and  vomiting  may  indicate  either  a  constitu- 
tional '*  medical  condition"  or  a  serious  surgical  disease. 

(6)  The  first  three  groups  of  causes  can  usually  be  discov- 
ered or  eliminated  by  the  history,  examination,  or  careful 
observation. 

(c)  Organic  surgical  lesions  of  the  various  structures  may 
be  more  or  less  evident  from  the  history  or  examination,  and 
will  be  considered  under  special  sections. 

(d)  Many  cases  of  chronic  or  recurring  indigestion  are 
caused  by  definite  surgical  lesions,  the  nature  of  which  can  be 
discovered  only  at  exploratory  operation. 

(c)  In  instances  of  definite  disturbance  where  constitutional 
or  nervous  disease  and  the  element  of  chronic  intoxication  can 
be  eliminated,  the  question  of  an  obscure  surgical  lesion  (gas- 
tric ulcer,  cholecystitis,  chronic  appendicitis)  and  especially 
malignant  disease  must  be  seriously  considered.  Exploratory 
operation  is  often  advised  in  order  to  make  a  diagnosis  and 


174       ESSENTIALS  OF  SURGERY  FOR  NURSES 


prevent  the  development  of  serious  complications,  or  inoper- 
able cancer  by  early  radical  removal. 

The  Stomach  (Fig.  38)  is  located  in  the  upper  abdomen 
in  the  epigastric  and  left  hypochondriac  regions.  (See  Anatomy 
and  Physiology  for  the  relations  and  structure.)  Surgical 
lesions  of  the  stomach  include:  (1)  Malformations,  congenital 
and  acquired;  (2)  wounds  and  foreign  bodies;  (3)  ulcer,  and 
(4)  malignant'  disease. 

CYSTIC  OUCr^       HEPAT/C  DUCT 


DIAPHRAGM- 

LIVER 

fi£mV£D 


GALL 
BLADDER 

PIGHT 

/SIDNEY- 
COMMON 
BILE  DUCT 
PANCREAS 
DUODENUM 


PLEEN 


LEET 
KIDNEY 


URETER  W  W  URETER 

Fig.  38. — Relations  of  stomach,  duodenum,  pancreas,  and  spleen. 


1.  Malformations. — (a)  Congenital  stenosis  of  the  pyloric 
region,  with  or  without  hypertrophy,  is  an  important  condition, 
seen  usually  in  new-born  infants.  It  is  characterized  by  par- 
tial or  complete  constriction  of  the  pylorus,  often  to  a  degree 
preventing  passage  of  contents  of  the  stomach  into  the  intestine. 
There  is  constant  or  recurrent  vomiting,  and  regurgitation  of 
stomach  contents,  marked  loss  of  weight,  malnutrition,  dis- 
tention of  the  upper  abdomen,  and  abnormal  stools.  Certain  of 
the  cases  are  due  to  spasm  of  the  circular  muscle  of  the  pylorus, 
and  are  relieved  by  suitable  medical  and  dietetic  treatment. 
Others  are  caused  by  actual  malformation  with  stricture  or 
occlusion  of  the  lumen,  and  the  effects  persist  in  spite  of  most 


THE  GASTRO-INTESTINAL  ORGANS  175 

careful  treatment.  The  condition  is  recognized  by:  (i)  the 
use  of  the  stomach-tube,  (ii)  examination  of  the  stools,  and 
(iii)  the  rapidly  developing  malnutrition  from  starvation.  It  is 
most  important  that  the  nature  of  the  condition  be  promptly 
recognized  in  order  that  proper  treatment  be  instituted  before 
the  effects  of  starvation  are  too  great. 

Surgical  treatment  is  indicated  where  there  is  complete 
obstruction,  since  if  this  is  not  relieved  the  child  will  die  of 
starvation.  The  operation  will  consist  of  either  a  gastro-enter- 
ostomy,  a  plastic  operation  on  the  pylorus,  or  a  simple  enter- 
ostomy for  temporary  feeding. ' 

(6)  Acquired  malformations  consist  of  strictures  which  are 
secondary  to  ulcers  or  cancer,  and  cause  obstruction  to  the 
normal  passage  of  stomach  contents.  The  "hour-glass"  stom- 
ach is  caused  by  the  constriction  of  scar  tissue  from  an  ulcer  of 
the  "lesser  curvature,"  resulting  in  a  constriction  through  the 
middle  of  the  organ,  which  is  thus  incompletely  divided  into  two 
pouches.  The  condition  is  recognized  by  Rontgen  ray  exami- 
nation after  feeding  with  bismuth  mixtures.  Treatment  may 
be  indicated  where  drainage  of  one  of  the  pouches  is  incomplete 
and  there  is  retention  of  contents.  Surgical  operation  may  con- 
sist of  plastic  reconstruction  of  the  stomach  or  an  anastomosis 
between  the  two  sacs.  Stricture  at  the  pylorus,  due  to  ulcer  or 
cancer,  is  more  common,  and  is  often  preceded  by  a  more  or  less 
suggestive  history  of  gastric  ulcer  or  chronic  indigestion.  The 
result  is  an  enlarged,  dilated  stomach,  with  retention  of  con- 
tents. Evidences  are :  regurgitation  or  vomiting  of  food  which 
has  been  taken  several  hours  previously.  Gastric  lavage  dem- 
onstrates a  retention  of  stomach  contents.  This  can  be  con- 
firmed by  studies  with  bismuth  feeding  and  X-ray  examinations. 
Positive  findings  indicate  pyloric  obstruction  sufficient  to 
demand  treatment  to  secure  proper  drainage,  regardless  of 
the  cause. 

Principles  of  Treatment. — (i)  Excision  of  the  area  of  con- 
striction with  reconstruction  of  the  tract  (anastomosis  between 
the  stomach  and  small  intestine),  (ii)  Anastomoses  between 
the  duodenum  and  stomach,  "pyloroplasty."  (iii)  Simple 
gastro-enterostomy  which  prevents  retention  of  contents  in 
the  stomach,  and  reheves  irritation  from  the  passage  of  stomach 
contents  at  the  area  of  constriction  or  ulceration. 


176       ESSENTIALS  OF  SURGERY  FOR  NURSES 

(c)  Acute  dilatation  of  the  stomach  (see  page  174)  consists 
of  a  spastic  closing  of  the  pylorus  and  often  of  the  cardiac  open- 
ing resulting  in  retention  of  contents,  atony  of  the  stomach 
wall,  and  extreme  dilatation  of  that  organ.  The  stomach  is  unable 
to  expel  its  contents,  may  reach  tremendous  size  and  embarrass 
respiration  or  cardiac  action  by  mechanical  pressure.  Treat- 
ment: Gastric  lavage  done  as  early  as  the  condition  is  sus- 
pected and  repeated  at  frequent  intervals,  since  the  dilatation 
often  recurs. 

2.  Wounds  penetrating  the  wall  of  the  stomach  result  in  a 
rapidly  spreading,  diffuse  peritonitis,  and  call  for  prompt 
surgical  rehef.  (See  page  169.)  Foreign  bodies  which  are 
swallowed  are  likely  to  be  retained  in  the  stomach  and  are 
usually  recognized  by  X-ray  plates  or  fluoroscopic  examination. 
Dangers  are :  Irritation  of  the  stomach,  penetration  of  the  wall, 
or  ulceration  through,  and  peritonitis.  Prompt  removal  by 
surgical  operation  is  indicated. 

3.  Ulcers  of  the  stomach  and  duodenum,  while  distinct 
anatomically,  present  similar  clinical  findings  and  symptoms. 
Causes  are  indefinitely  understood,  though  there  are  many 
underlying  factors: 

(a)  Infection  in  other  parts  of  the  body.  The  streptococcus 
is  closely  associated  as  a  cause  and  may  be  derived  from  a  pre- 
vious tonsillitis  or  appendicitis. 

(h)  Diet  and  habits  of  eating  have  an  indirect  influence  in 
causing  ulcer,  and  certain  dietary  restrictions  are  necessary  in 
the  treatment. 

(c)  Hyperacidity,  i.e.,  increase  in  the  hydrochloric  acid,  is 
present  in  most  cases  of  ulcer.  This  is  sometimes  claimed  to  be 
a  cause  of  the  condition,  and  certainly  increases  the  symptoms 
and  pain.  It  is  well  known  that  alkalis  (sodium  bicarb.)  re- 
lieve the  pain  and  discomfort  and  have  a  favorable  influence  on 
the  course  of  the  disease. 

Course  and  Symptoms. — The  course  is  somewhat  chronic. 
The  condition  begins  as  an  erosion  in  the  mucous  membrane 
and  extends  as  an  open  ulcer  on  the  surface.  Complete  healing 
with  no  deformity  or  scar  is  possible,  but  in  many  cases  excessive 
scar  tissue  persists,  with  contraction  or  stricture,  especially  in 
ulcers  of  the  pjdorus  or  duodenum.  Extension  through  the  wall 
of  the  stomach  with  localized  peritonitis,  or  sudden  rupture 


THE  GASTRO-INTESTINAL  ORGANS  177 

of  the  weakened  ulcer  base  and  acute  general  peritonitis  are 
occasional  results.  The  term  chronic  ulcer  refers  to  certain 
ones  which  persist  due  to  repeated  or  continued  irritation,  with 
resulting  deformity  or  lesions  causing  persistent  digestive 
disturbances. 

Symptoms. — (a)  Pain  in  the  region  of  the  stomach  is  a 
prominent  symptom  in  most  cases.  This  is  characterized  by  the 
fact  that  it  appears  from  two  to  four  hours  after  eating  when 
the  stomach  is  empty,  being  a  "hunger-pain."  It  is  relieved  by 
taking  food  or  by  the  use  of  large  doses  of  sodium  bicarbonate, 
either  of  which  acts  by  neutralizing  the  free  hydrochloric  acid 
which  irritates  the  ulcer  and  causes  pain. 

(6)  Local  tenderness  is  generally  evident. 

(c)  "Hsematemesis,"  vomiting  of  blood,  is  usually  present 
at  some  time  and  may  present  the  first  definite  indication  of 
the  nature  of  the  lesion.  The  vomiting  of  a  considerable  amount 
of  fresh  free  blood  is  important  evidence  of  gastric  ulcer,  and 
may  present  urgent  indications  for  treatment. 

{d)  "Occult  blood"  in  the  stools  may  be  demonstrated  by 
suitable  tests  in  a  large  percentage  of  cases,  especially  ulcers  of 
the  duodenum. 

(e)  Acid  regurgitations  are  frequently  present,  but  vomiting 
is  not  a  characteristic  symptom  unless  there  is  obstruction  of 
the  pylorus  and  food-retention.  Secondary  s3rmptoms  include: 
anemia  from  hemorrhage,  loss  of  weight  and  malnutrition 
from  continued  digestive  disturbance,  and  complications. 

Complications. — (a)  Hemorrhage,  when  of  considerable 
amounts,  or  repeated,  may  threaten  fife  and  be  fatal,  or  result 
in  a  high-grade  anemia.  At  times  it  is  the  first  indication 
of  serious  gastric  disease,  but  may  occur  at  any  stage.  Special 
indications  for  treatment  are :  Absolute  rest  in  bed  and  immo- 
bilization of  the  gastro-intestinal  tract  by  adequate  doses  of 
morphine,  withholding  of  foods  and  fluids  by  mouth,  and  the 
ice-bag  locally.  Enemas  and  rectal  feeding  are  used  later,  till 
the  hemorrhage  is  controlled,  when  a  careful  return  is  made  to 
fluids  by  mouth,  and  suitable  treatment  of  the  ulcer  is  instituted. 
In  some  cases  the  surgeon  will  wash  the  stomach,  using  an 
alkali,  sodium  bicarbonate  or  adrenalin.  The  evacuation  of 
clots  relieves  irritation  and  lessens  the  tendency  to  recurrence  of 
bleeding.  In  a  few  selected  instances,  surgical  operation  may  be 
12 


178       ESSENTIALS  OF  SURGERY  FOR  NURSES 

advised  to  control  the  bleeding,  though  there  is  great  difference 
of  opinion  on  this  point. 

(b)  Perforation  and  rupture  of  a  gastric  ulcer  often  occurs 
with  no  warning  and  only  indefinite  evidence  of  previous  dis- 
turbance. The  most  typical  and  dramatic  attack  follows  rup- 
ture of  an  ulcer  on  the  anterior  wall  of  the  stomach,  resulting 
in  sudden  diffuse  peritonitis.  There  is  sharp,  severe  abdominal 
pain  and  prostration,  rapid  pulse,  rising  temperature,  rigid, 
distended  abdomen,  making  the  picture  striking.  Prompt 
surgical  treatment  is  most  urgently  indicated  within  the  first 
few  hours.  The  prognosis  grows  rapidly  more  hopeless  as  this 
is  delayed.  Objects  to  be  accomphshed  by  operation  are: 
Closure  of  the  perforation  and  drainage  of  the  peritonemn,  and 
if  possible,  surgical  treatment  of  the  ulcer,  excision  or  gastro- 
enterostomy. Perforation  of  an  ulcer  on  the  posterior  wall  of 
the  stomach  results  in  a  localized  peritonitis  and  abscess  forma- 
tion, more  gradual  in  development  and  with  less  urgent  indi- 
cations for  surgical  relief. 

(c)  Development  of  a  clironic  ulcer,  with  persistent  or  recur- 
rent symptoms,  and  deformit}^  from  contracting  scar  tissue. 
This  is  an  occasional  sequel  of  the  acute  tj^e  of  ulcer  and  indi- 
cates that  healing  and  cure  is  incomplete.  Definite  persistent 
food  retention  is  evidence  of  constriction  at  the  pylorus  and  is 
one  indication  for  operative  treatment. 

{d)  The  relation  to  malignant  disease,  cancer.  There  is 
suggestive  evidence  that  a  heahng  chronic  ulceration  may  give 
rise  to  the  development  of  malignant  disease  in  a  considerable 
number  of  cases,  and  this  fact  is  an  indication  for  radical  surgi- 
cal excision  of  chronic  ulcers  of  the  stomach.  On  the  other  hand, 
cancer  of  the  stomach,  in  the  early  stages,  may  be  mistaken 
clinically  for  chronic  ulcer  and  undergo  serious  extension  while 
the  case  is  being  treated  conservatively.  These  facts,  therefore, 
present  definite  indication  for  exploratory  operation,  in  doubtful 
or  persistent  cases. 

Principles  of  Treatment. — (a)  Medical  treatment,  to  be  ade- 
quate, must  be  systematic  and  persistent,  including  several  weeks 
of  careful  diet,  with  suitable  medication.  Nothing  less  than  such  a 
course  under  the  care  of  a  conscientious  medical  man,  preferably 
in  a  hospital,  should  be  considered  for  any  case  where  a  diag- 
nosis of  gastric  ulcer  has  been  made.    When  this  is  done  a  con- 


THE  GASTRO-INTESTINAL  ORGANS  179 

siderable  number  of  cases  will  recover  completely  with  no 
complications  or  after-effects.  However,  in  spite  of  such  treat- 
ment, a  certain  group  of  cases  will  persist  and  require  surgical 
treatment. 

(6)  Indications  for  surgical  treatment  are:  (i)  Rupture  of 
an  ulcer,  with  general  peritonitis  or  locahzed  abscess,  (ii)  Cases 
where  thorough  medical  treatment  is  for  any  reason  impossible, 
(iii)  Cases  which  persist  or  grow  worse  in  spite  of  medical  treat- 
ment, (iv)  Chronic  cases  with  suspicion  of  cancer  or  evidences 
of  food  retention.  Surgical  treatment  may  consist  of:  (a)  Ex- 
cision of  the  ulcer  and  reestablishment  of  the  continuity  of  the 
gastro-intestinal  tract  by  suitable  anastomosis.  This  is  the 
ideal  procedure,  but  involves  much  manipulation  and  more 
danger  of  shock.  (6)  Gastro-enterostomy  may  be  done  to 
reheve  pyloric  obstruction,  food  retention,  and  prevent  further 
irritation  of  the  ulcer  area.  This  operation  is  essentially  a  palha- 
tive  one  but  results  in  a  large  number  of  cures. 

4.  Cancer  of  the  stomach  occurs  most  commonly  in  the 
pyloric  region  of  the  stomach,  and  in  individuals  over  forty 
years,  though  sometimes  found  at  an  earher  age.  The  causes 
are  discussed  under  the  question  of  cancer  (see  page  46).  Of 
particular  clinical  interest  is  the  relationship  to  chronic  ulcer  as 
mentioned  under  that  subject.  The  early  symptoms  are  not 
specific,  and  are  those  of  chronic  or  recurring  indigestion,  with 
evidences  of  food  retention  in  the  stomach.  The  important 
consideration  is,  that  the  occurrence  of  such  attacks  in  an  indi- 
vidual who  has  been  previously  well,  and  with  no  constitu- 
tional causes,  is  strong  presumptive  evidence  of  organic  surgical 
lesion,  possibly  cancer.  It  happens  not  infrequently  that  such 
cases  which  appear  cUnically  to  be  due  to  constitutional  or 
dietetic  causes,  or  possibly  to  chronic  ulcer,  develop  while  under 
observation,  and  are  recognized  as  cancer  only  when  they  have 
become  inoperable.  It  is  most  urgent  that  such  doubtful  cases 
where  cancer  cannot  be  reasonably  excluded,  be  given  the  ben- 
efit of  exploratory  laparotomy  early  in  the  course,  if  there  is  to 
be  hope  of  successful  cure. 

The  characteristic  evidences  of  gastric  cancer:  Palpable 
tumor,  typical  findings  in  the  stomach  contents,  loss  of  weight, 
mal-nutrition,  and  cachexia,  indicate  advanced  disease  which 
too  often  is  inoperable.    The  presence  of  metastatic  growths  in 


180       ESSENTIALS  OF  SURGERY  FOR  NURSES 

other  parts  of  the  body,  particularly  the  liver,  indicate  an  inop- 
erable condition  with  a  hopeless  prognosis. 

Operative  treatment  may  be:  (a)  Radical  removal  of  a 
portion  of  the  stomach  and  gastro-enterostomy,  which  is  the 
ideal  procedure,  is  indicated  in  early  locahzed  growths.  (6)  Pal- 
liative gastro-enterostomy  is  done  in  late  cases  with  food  reten- 
tion causing  persistent  vomiting,  and  is  followed  by  marked 
temporary  improvement. 

THE  INTESTINAL  TRACT 

This  includes  the  small  intestine,  vermiform  appendix,  large 
intestine  or  colon,  and  the  rectum  and  anus.  It  is  conveniently 
considered  under  separate  heads:  Lesions  of  the  entire  tract, 
obstruction.  Lesions  of  the  small  intestine.  Lesionsof  the  colon. 
Lesions  of  the  rectum  and  anus.  Lesions  of  the  vermiform 
appendix. 

Lesions  of  the  entire  tract.  "  Ileus  "  intestinal  obstruction: 
(A)  sudden,  complete  obstruction.  (B)  Incomplete  or  gradual 
obstruction,  usually  secondary  to  other  lesions  of  the  tract. 

A.  Sudden  complete  obstruction  of  the  intestinal  tract 
may  be  caused  by:  (1)  Strangulated  hernia,  (a)  External,  in- 
guinal or  femoral  hernia  (this  tj^e  has  already  been  considered 
under  hernia;  see  page  163),  or  (6)  internal  hernias  into  bands 
of  adhesions  secondary  to  inflanmaatory  processes,  or  folds  of 
omentum. 

2.  Volvulus,  the  rotation  of  a  loop  of  intestine,  usually 
sigmoid,  upon  its  mesentery,  occluding  the  lumen  of  the  bowel, 
and  cutting  off  the  blood  supply.    (See  Fig.  39.) 

3.  Intussusception,  or  invagination  of  a  portion  of  the  intes- 
tine into  the  part  distal  to  it.  This  may  be  due  to  malformation 
of  the  intestine  or  mesentery  associated  with  irregular  peristalsis, 
and  is  found  most  often  at  or  near  the  ileo-csecal  junction.  It 
occurs  most  frequently  in  children.    (See  Fig.  40.) 

4.  Occlusion  of  the  lumen  by  foreign  bodies.  Example, 
gall-stones  which  have  ulcerated  into  the  intestinal  tract,  or 
fecal  concretions. 

5.  Ileus  paralyticus,  paralysis  of  the  intestinal  walls  without 
mechanical  obstruction,  may  be  secondary  to  peritonitis  and 
distention,  or  to  more  remote  causes,  reflex  disturbance  of  the 
sympathetic  nerve  supply. 


THE  GASTRO-INTESTINAL  ORGANS 


181 


6.  Stricture  of  the  intestine  from  ulcerations  due  to  tuber- 
culosis or  malignant  disease,  in  which  cases  there  is  usually 
historyof  digestive  disturbances  or  previously  partial  obstruction. 

Effects  and  symptoms: 

1.  Distention  of  the  abdomen  due  to  accumulation  of  gas  in 
the  intestinal  tract  proximal  to  the  obstruction. 


OBST/?i/Cr/0/V 


Fig.  39. — Volvulus  of  sigmoid. 

2.  Vomiting,  which  is  more  or  less  constant,  and  is  increased 
by  taking  fluids  or  cathartics  by  mouth.  Later  there  is  regur- 
gitation of  intestinal  contents  and  the  vomiting  becomes  fecal 
in  character. 

3.  Pain  due  to  the  distention,  vomiting,  and  active   peri- 


182       ESSENTIALS  OP  SURGERY  FOE  NURSES 


stalsis,  which  is  increased  by  foods,  fluids,  or  cathartics  taken 
by  mouth. 

4.  Constipation,  usually  absolute,  with  no  passage  of  flatus  or 
faeces.  Cathartics  by  mouth  increase  the  pain  and  vomiting  by 
causing  ineffective  intestinal  peristalsis.  They  are  contra- 
indicated  in  cases  suggesting  obstruction.  Enemas  are  usually 
unproductive  but  do  no  positive  harm,  and  should  be  tried  in 
all  suspicious  cases. 


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'/?£n//?Mm 
i/iy£/f 


6//£/fr//, 


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Fig.  40. — Intxissusception. 

In  certain  instances  of  volvulus,  high  enemas  may  overcome 
the  obstruction.  In  case  of  a  lesion  high  in  the  tract,  or  of  in- 
tussusception, there  may  be  one  or  more  scanty  movements, 
often  containing  blood  or  mucus. 

5.  Shodz  and  prostration  is  usually  present  early  in  the 
course,  due  to  the  pain  and  distress.  Later  there  is  toxaemia 
and  sepsis  caused  by  absorption  of  toxines  from  the  tract,  or 
gangrene  of  strangulated  portions  of  the  intestine,  eventually 
causing  death  in  spite  of  treatment.    The  onset  is  sudden,  with 


THE  GASTRO-INTESTINAL  ORGANS  183 

severe  pain,  persistent  vomiting  which  becomes  fecal  in  charac- 
ter, distention  of  the  abdomen,  and  lack  of  bowel  movement. 
Within  a  few  hours  there  is  marked  prostration,  followed  by 
toxsemia  and  sepsis.  High  enemas  are  ineffective.  Progress 
is  rapid  and  the  condition  is  fatal  unless  relieved  within  from 
thirty-six  to  seventy-two  hours,  before  marked  toxsemia  is 
present.  The  prognosis  is  usually  good  provided  the  obstruction 
is  reheved  within  twenty-four  hours,  but  grows  rapidly  unfa- 
vorable if  this  is  delayed.  Evidence  of  toxsemia  or  sepsis  indi- 
cates a  grave  prognosis.  The  presence  of  a  strangulated  hernia, 
acute  inflammation  in  the  abdomen,  post-operative  peritonitis, 
or  previous  gastro-intestinal  disturbance  may  suggest  the 
diagnosis.  The  clinical  picture  is  fairly  typical  and  is  usually 
recognized.  Failure  to  make  a  safe  early  diagnosis  and  the  use 
of  cathartics  or  morphine  during  the  early  stage  are  responsible 
for  dangerous  delay,  aggravation  of  symptoms,  and  many  fatal 
results. 

Principles  of  Treatment. — (1)  Palhative.  Vomiting  is  best 
controlled  by  withholding  food  and  fluids  by  mouth,  and  by  gastric 
lavage.  Pain  is  relieved  by  the  same  measures,  and  the  use  of 
an  ice-bag.  Morphine  is  dangerous  in  that  it  masks  the  pain 
which  is  an  important  indication  of  the  severity  of  the  condition. 
It  should  be  used  only  on  the  direct  order  of  the  physician :  (a) 
After  the  operation  has  been  arranged  for.  (6)  In  certain  early 
cases  of  volvulus  with  high  enemas,  thus  attempting  to  over- 
come the  obstruction. 

2.  Surgical  treatment  aims:  (a)  to  reheve  the  obstruction, 
and  (6)  to  re-establish  the  patent  lumen  of  the  intestinal  tract 
by  (i)  operative  reduction  of  a  strangulated  hernia;  (ii) 
correction  of  a  volvulus;  (iii)  reduction  of  an  intussusception; 
(iv)  drainage  of  peritoneum,  and  (v)  excision  of  gangrenous 
intestine,  with  suitable  anastomosis.  Certain  desperate,  neg- 
lected cases  are  so  prostrated  by  toxaemia  at  the  first  operation 
that  nothing  more  is  possible  than  an  enterostomy,  opening  the 
intestine  above  the  obstruction  to  drain  the  tract  of  toxic  ma- 
terial, and  relieve  immediate  symptoms.  The  remainder  of 
the  operation  is  delayed  till  the  acute  obstructive  symptoms 
are  overcome  and  the  condition  of  the  patient  is  improved. 
Cases  of  "ileus  paralyticus"  often  present  no  gross  anatomical 
lesion  which  can  be  treated  surgically,  and  the  physician  must 


184       ESSENTIALS  OF  SURGERY  FOR  NURSES 

use  other  measures,  high  enemas  of  oil  and  glycerin,  soapsuds 
and  turpentine  enema,  etc.,  together  with  certain  drugs  to  stim- 
ulate intestinal  peristalsis,  eserin  or  pituitrin  hypodermically. 

B.  Gradually  developing  complete  or  partial  obstruction 
may  be  caused  by:  (1)  Constriction  or  stricture,  due  to  scar 
tissue  of  ulcers,  tuberculous  or  malignant.  (2)  Pressure  of  an 
abdominal,  ovarian,  or  pelvic  tumor.  (3)  Congenital  or  in- 
flammatory bands  or  adhesions. 

There  is  usually  a  history  of  preceding  gastro-intestinal 
disturbances,  pain,  distention,  constipation,  or,  in  some  cases, 
alternating  constipation  and  diarrhoea.  If  the  lesion  is  in  the 
pelvis  or  lower  colon,  there  may  have  been  ribbon-like  stools. 
In  case  of  fresh  ulceration  or  mahgnant  disease  of  the  intestine, 
there  will  be  gross  bleeding  or  occult  blood  in  the  stools.  In- 
flammatory conditions  will  be  associated  with  an  elevation  of 
temperature  and  evidence  of  sepsis. 

The  onset  of  complete  obstruction  may  be  sudden,  but  there 
is  usually  a  suggestive  history  of  previous  gastro-intestinal 
disturbance.  The  symptoms  are  less  urgent,  the  constipation 
is  often  reUeved  temporarily  by  enemas,  but  recurrence  is 
common.  Later  there  is  constitutional  evidence  of  a  serious 
lesion,  infection  or  tumor.  Diagnosis  of  the  nature  of  the  case 
can  often  be  made  from  the  history,  careful  observation  during 
an  attack,  and  examination,  especially  with  bismuth  meals  or 
enemas,  and  X-ray  plates. 

Principles  of  Treatment. — (1)  PalHative  measures  often  serve 
to  relieve  the  acute  condition^  after  which  the  case  can  be  studied 
and  elective  operation  advised  as  indicated.  (2)  Surgical 
measures  may  be  necessary  as  in  acute  obstruction,  except  that 
removal  of  the  cause  is  often  postponed  for  secondary  operation. 
(3)  Definite  evidence  of  organic  obstruction  is  an  indication 
for  exploratory  operation,  since  this  is  often  the  only  early  sign 
of  mahgnant  disease  of  the  intestinal  tract  at  a  stage  when  suc- 
cessful removal  is  possible. 

Small  Intestine. — The  ''duodenum"  (see  Fig.  38),  includiHg 
the  first  twelve  or  fourteen  inches  of  the  small  intestine  contin- 
uous with  the  stomach,  is  closely  attached  to  the  posterior  body 
wall,  and  lies  in  close  relation  to  the  gall-bladder,  pancreas,  and 
right  kidney,  and  is  continuous  with  the  movable  part  of  the 
small  intestine  at  a  fixed  point  behind  the  stomach.    The  re- 


THE  GASTRO-INTESTINAL  ORGANS  185 

mainder  of  the  small  intestine  is  suspended  in  a  free  fold  of 
mesentery,  and  is  divided  anatomically  into  the  '^ jejunum," 
comprising  the  upper  portion,  and  the  "ileum,"  including  about 
the  lower  two-thirds.  The  two  portions  are  continuous,  wdth 
no  definite  line  of  demarcation,  but  differ  somewhat  in  structure. 
Lesions  of  the  small  intestine  include:  (A)  Wounds,  (B) 
ulcers,  (C)  cancer. 

A.  Wounds  penetrating  the  intestine  are  most  often  the 
result  of  gunshot,  in  which  case  there  are  usually  several  per- 
forations in  various  parts  of  the  tract.  Peritonitis  is  inevitable 
and  is  most  often  fatal  unless  controlled  by  prompt  operation, 
repair  of  perforations,  and  drainage.  In  a  few  cases  where 
surgical  rehef  is  not  accessible  for  a  number  of  hours,  and  the 
patient  survives  the  resulting  peritonitis,  palliative  operative 
measures  are  delayed  till  a  locahzed  abscess  forms,  which  is 
then  opened  and  drained. 

B.  Ulcers  include  three  varieties:  (1)  Duodenal,  (2)  ty- 
phoid, (3)  tuberculous. 

1.  Ulcers  of  the  duodenum  are  similar  in  their  clinical  effects 
to  those  of  the  pyloric  region,  with  the  foUowing  exceptions: 
(a)  The  pain  comes  on  longer  after  eating,  from  four  to  six 
hours,  but  is  reheved  by  food  and  by  alkahs.  (6)  Perforation, 
when  it  occurs,  is  into  the  free  peritoneal  cavity  and  the  results 
are  even  more  disastrous  than  those  from  ruptured  gastric 
ulcers,  (c)  Hemorrhage  is  not  so  evident  in  the  stomach  con- 
tents, but  is  seen  in  the  stools,  or  demonstrated  as  "occult 
blood"  by  suitable  tests,  (d)  Malignant  disease  is  compara- 
tively rare  in  the  duodenum. 

2.  Typhoid  ulcerations  occur  in  the  "Peyer's  patches"  of  the 
ileum,  and  cause  two  important  complications:  (a)  Concealed 
hemorrhage,  which  is  treated  on  general  principles  (see  page  54) ; 
(6)  perforation  or  rupture  of  an  ulcer  wdth  rapidly  spreading 
diffuse  peritonitis  which  is  fatal  in  the  absence  of  prompt  sur- 
gical treatment,  drainage,  and  closure  of  the  ulcer.  Normally 
the  typhoid  ulcers  heal  with  no  deformity  or  after-effects  in 
the  intestinal  wall. 

3.  Tuberculous  ulcers  may  occur  at  any  level  of  the  intestinal 
tract  and  are  transverse  to  the  long  axis  of  the  bowel.  In  healing 
they  are  likely  to  cause  constriction  of  the  lumen  of  the  tract. 
They  may  also  extend  to  the  peritoneum  with  the  development 


186       ESSENTIALS  OF  SURGERY  FOR  NURSES 

of  tubercular  peritonitis,  or  large  masses  of  inflammatory  tissue 
in  the  wall  of  the  intestine. 

C.  Malignant  disease  of  the  small  intestine  is  quite  rare 
and  there  are  no  characteristic  symptoms  in  the  early  stages. 
It  is  discovered  accidentally  at  operation  as  a  cause  of  intestinal 
obstruction  or  obscure  disturbances. 

Large  Intestine,  "colon."  Anatomically  this  is  divided 
into :  the  ''  cecum  "  and  "  ascending  colon  "  on  the  right  side,  the 
"hepatic  flexure"  in  relation  to  the  liver,  the  "transverse  colon" 
extending  across  the  abdomen  attached  to  the  greater  curvature 
of  the  stomach,  the  "splenic  flexure"  and  "descending  colon" 
on  the  left  side,  the  "sigmoid  flexure"  with  its  mesentery  lying 
freely  in  the  pelvis,  and  continuous  with  the  "rectum,"  which 
extends  along  the  sacrum  to  the  external  opening  at  the  "anus." 
The  colon  is  larger  in  circumference  than  the  small  intestine  and 
is  characterized  by  the  "longitudinal  bands,"  and  by  the  nu- 
merous folds  of  fat  "appendices  epiploicse"  which  are  attached 
to  the  colon  and  hang  freely  in  the  peritoneal  cavity. 

Surgical  lesions  include:  (A)  Congenital  or  inflammatory 
constrictions  and  malpositions.  (B)  Fistulse:  (1)  accidental, 
(2)  operative.  (C)  Inflammatory  lesions,  ulcers  and  diverti- 
culitis.    (D)  Mahgnant  disease. 

A.  Congenital  constriction  or  occlusion  is  a  rare  con- 
dition present  in  the  new-bom.  If  the  occlusion  is  absolute,  as 
indicated  by  absence  of  bowel  movement,  surgical  relief  is 
necessary  at  once.  This  may  consist  of:  (1)  A  "colostomy" 
above  the  obstruction,  or  (2)  an  anastomosis  between  the  por- 
tions of  the  intestine  above  and  below  this  point. 

Malposition  of  the  colon  may  occur:  (1)  As  a  congenital 
anomaly,  and  cause  symptoms  of  obstruction  only  under  certain 
conditions.  (2)  As  a  result  of  "ptoses"  and  relaxation  of  the 
abdominal  walls.  (Seep.  160.)  (3)  From  inflammatory  adhesions 
fixing  a  portion  of  the  colon  in  an  abnormal  position.  Example: 
The  transverse  colon  becomes  adherent  to  a  pelvic  abscess. 
Results:  There  is  a  "stasis"  of  intestinal  contents  with  consti- 
pation and  secondary  effects,  "colitis."  The  condition  is  rec- 
ognized by  Rontgen-ray  plates  taken  after  bismuth  meals  have 
reached  the  colon,  or  enemas  of  similar  mixtures  have  been  given. 

Operative  measures  are  of  value  only  in  certain  cases  and 
include:    (1)  Releasing   adhesion.      (2)  Suture  of  the  bowel, 


THE  GASTRO-INTESTINAL  ORGANS  187 

fixing  it  in  normal  position.  (3)  Anastomoses,  or  "siiort- 
circuiting  operations,"  which  throw  the  involved  portion  of  the 
colon  out  of  function.  (4)  Resection  of  the  diseased  colon  in 
certain  selected  cases. 

B.  A  FISTULA  or  abnormal  opening  into  the  colon  includes 
two  types:  (1)  Accidental  fecal  fistula  complicating  abscess  or 
operation.  Example:  A  fecal  fistula  into  the  cecum  following 
operation  for  appendicitis,  usually  in  cases  where  the  cecum  is 
involved  in  the  inflammation.  Spontaneous  closure  is  the  rule. 
In  occasional  cases  operation  is  necessary,  and  consists  of:  (a) 
Excision  of  the  fistulous  tract ;  (6)  suture  of  the  intestinal  open- 
ing, and  (c)  closing  the  muscle  and  skin  wound. 

(2)  Therapeutic  fistula,  "colostomy,"  or  artificial  anus,  is 
made  to  secure  an  opening  into  the  intestinal  tract  in  cases :  (a) 
When  there  is  an  intestinal  obstruction  below  that  point,  which 
cannot  be  reheved  at  the  first  operation.  (6)  In  cases  of  chronic 
infection  or  ulceration  of  the  colon,  to  secure  rest,  relieve  irri- 
tation of  the  diseased  portion,  and  allow  treatment  by  irrigation, 
(c)  In  case  of  cancer  of  the  colon  or  rectum,  either  for  a  perma- 
nent anus,  or  as  a  preliminary  step  to  radical  removal  of  the 
growth.  Under  favorable  conditions  such  a  fistula  causes  only 
slight  inconvenience  and  gives  satisfactory  results. 

C.  Inflammatory  Lesions. — (1)  Ulcers.  Tuberculous  ulcer- 
ation is  most  frequent  about  the  cecum  and  may  form  a  large 
mass  of  inflammatory  tissue  or  occlude  the  lumen  of  the  intes- 
tine. Resection  of  the  involved  portion  and  suitable  anasto- 
moses may  be  done  in  selected  cases,  followed  by  constitutional 
treatment.  (2)  "Colitis."  Ulcers  and  chronic  infection  of  the 
large  intestine  are  not  infrequent,  and  are  associated  with 
changes  in  the  mucous  membrane,  thickening  of  the  wall,  and 
possibly  constrictions  from  scar  tissue.  These  conditions  are 
insidious  in  their  onset,  being  characterized  by  frequent, 
painful  bowel  movements,  blood  and  mucus  in  the  stools, 
malnutrition,  loss  of  weight,  and  secondary  anemia.  Con- 
strictions and  masses  occluding  the  lumen  may  give  rise  to 
intestinal  obstruction. 

Principles  of  Treatment. — Certain  ulcers  low  in  the  sigmoid 
or  rectum  can  be  treated  with  local  applications  or  irrigations. 
If  the  condition  is  extensive  and  chronic,  more  radical  surgical 
measures  are  necessary,     (a)  "Colostomy"  or  enterostomy  is 


188       ESSENTIALS  OF  SURGERY  FOR  NURSES 

done  above  the  level  of  the  lesion,  thus  reheving  the  inflamed 
area  from  irritation.  In  some  cases  irrigations  are  used  through 
the  colostomy  wound,  and  the  opening  is  maintained  for  several 
months.  This  is  often  followed  by  rapid  gain  in  weight,  and 
general  improvement,  as  well  as  cure  of  the  local  condition. 
(6)  Resection  of  the  diseased  bowel  may  be  indicated  in  cer- 
tain cases,  but  is  often  too  extensive  an  operation  for  the  con- 
dition of  the  patient. 

(3)  Diverticulitis  is  an  acute  inflanmiation  involving  congenital 
or  acquired  diverticulse  of  the  colon,  particularly  of  the  sigmoid 
flexure.  It  is  often  comphcated  by  local  abscess  formation, 
with  pain  and  fever,  or  evidence  of  partial  obstruction.  The 
condition  is  usually  obscure  in  onset.  Surgical  treatment  is 
necessary  and  may  consist  of:  (a)  Palliative  colostomy  for 
obstruction.  (6)  Drainage  of  an  abscess,  (c)  Resection  of 
the  colon  involved,  and  anastomosis,  though  this  procedure  may 
have  to  be  reserved  for  a  later  operation. 

D.  Malignant  disease  is  usually  cancer,  which  is  found 
most  often  in  the  cecum  or  sigmoid  flexure.  The  condition  may 
be  evident  as  a  developing  obstruction,  or  by  local  pain,  blood 
in  the  stools,  or  a  mass  which  can  be  palpated.  Rontgen-ray 
examination  will  indicate  a  stricture  or  obstruction  in  the  region 
of  the  colon  which  is  involved.  Cancer  of  the  colon  is  charac- 
terized by  the  fact  that  metastases  occur  late  in  the  course  of 
the  disease,  and  that  resection  is  followed  by  a  high  percentage 
of  cures. 

The  Rectum  and  Anus  include  the  lower  twelve  or  four- 
teen inches  of  the  colon  which  is  attached  to  the  sacrum,  open- 
ing to  the  exterior  at  the  anus. 

Surgical  lesions  include:  (A)  Malformations.  (B)  Ulcers, 
abscess,  and  fistula.     (C)  Hemorrhoids  and  fissure.     (D)  Cancer. 

A.  Malformations. — "Imperforate  anus,"  due  to  con- 
genital defect,  is  a  rare  condition  of  the  new-born,  recognized 
soon  after  birth  by  the  absence  of  meconium,  or  bowel  move- 
ment. The  condition  is  incompatible  with  hfe  unless  prompt 
operative  relief  is  successful.  This  may  consist  of  (1)  colos- 
tomy, or  (2)  in  some  cases  a  perineal  dissection  can  be  made, 
the  bhnd  end  of  the  colon  reached,  and  brought  down  to  the  anus. 

B.  Ulcers  of  the  rectum  occur  as  in  other  parts  of  the  colon, 
or_  associated  with  similar  lesions  throughout  the  large  intestine 


THE  GASTRO-INTESTINAL  ORGANS  189 

as  a  "colitis."  They  may  be  due  to  bacterial  infection,  broken- 
down  gummata,  polyps,  or  malignant  growths. 

Effects  are :  Painful  and  frequent  defecation,  blood,  mucus, 
or  pus  in  the  stools,  constriction  with  ribbon  stools,  or  obstruc- 
tion. The  nature  of  the  lesion  can  often  be  discovered  by 
direct  examination  with  a  proctoscope.  Treatment  is  local 
with  apphcations  or  irrigations.  In  cases  of  stricture  or  malig- 
nant growth  appropriate  operative  measures  will  be  indicated. 

Abscess,  usually  "perirectal"  abscess,  is  a  subacute  pro- 
cess developing  in  the  loose  perirectal^at.  This  infection  usually 
takes  place  from  the  skin  or  from  hemorrhoids,  and  may  reach 
considerable  size,  with  comparatively  httle  systemic  reaction, 
on  account  of  the  poor  local  blood-supply.  Even  after  free 
incision  there  is  a  marked  tendency  for  the  condition. to  become 
chronic,  with  a  persisting  sinus,  due  to  secondary  infection  with 
staphylococci,  B.  coH,  and,  not  infrequently,  tubercle  bacillus. 

"  Fistula  in  ano"  is  the  most  frequent  comphcation,  due  to 
an  extension  of  the  abscess  into  the  rectum  above  the  sphincter 
muscle,  and  through  the  skin  to  the  surface.  This  may  consist 
of  a  simple,  fairly  direct  fistulous  tract,  but  more  often  has 
several  openings  into  the  rectum  and  also  to  the  surface,  the 
tortuous  canals  lined  with  infected  granulations.  There  is  no 
tendency  to  spontaneous  closure  of  such  fistulous  communica- 
tions, and  these  persist  indefinitely  in  spite  of  local  treatment. 

Principles  of  treatment  depend  on  the  early  recognition  of 
a  perirectal  abscess  and  prompt  radical  surgical  treatment,  free 
incision  and  packing  to  insure  thorough  healing  from  the  bot- 
tom of  the  cavity.  Persisting  sinuses  and  fistulas  require  radical 
surgical  operation,  excision  of  the  tract  and  packing  the  canal 
with  gauze  to  secure  complete  heaUng  with  no  pockets. 

C.  Hemorrhoids  and  Fissure. — Hemorrhoids  consist  of 
varicose  dilatations  of  the  hemorrhoidal  veins  which  supply  the 
rectum.  "Internal  hemorrhoids"  are  formed  by  such  vascular 
tumors  under  the  mucosa,  and  project  into  the  rectum  just 
above  the  sphincter  muscle.  "External  hemorrhoids"  are  due 
to  a  similar  condition  of  the  veins  under  the  skin  in  the  region 
about  the  anus. 

Causes. — (l)  Habitual  constipation  and  straining  at  stool,  by 
mechanical  effect  cause  dilatation  of  the  hemorrhoidal  veins 
and  weakening  of  the  vascular  wall,  and  are  the  most  important 


190       ESSENTIALS  OF  SURGERY  FOR  NURSES 

factors  in  the  etiology  of  hemorrhoids.  (2)  Obstruction  of  the 
pelvic  veins  by  pressure  of  tumors,  or  a  pregnant  uterus.  (3) 
Occupations  requiring  long  standing,  heavy  Kfting,  or  repeated 
straining.  (4)  Constitutional  defects,  weak  vascular  walls  and 
supporting  tissue  about  the  rectum,  which  sometimes  amounts 
to  a  family  tendency.  (5)  Obstruction  to  the  portal  circu- 
lation, as  in  cirrhosis  of  the  liver. 

Complications. — (1)  Protrusion  of  the  hemorrhoids  through 
the  sphincter,  "hemorrhoids  coming  down,"  resulting  in  pain 
and  discomfort,  usually  relieved  by  rest  in  bed,  local  applications, 
or  careful  manipulations.  (2)  Hemorrhage,  ''bleeding  piles," 
from  rupture  of  the  vascular  swellings,  may  be  profuse  and 
frequently  repeated,  often  resulting  in  serious  anemia.  (3) 
Itching  and  pruritis  about  the  anus  and  perineum,  due  to  irri- 
tating secretion.  (4)  "Fissures"  and  cracks  in  the  rectal  mucosa 
at  the  sphincter,  causing  severe  pain  at  defecation.  This  is 
usually  associated  with  hemorrhoids  and  is  relieved  by  complete 
dilatation  of  the  sphincter  ani  muscle,  and  cauterization  of  the 
base  of  the  fissure.  (5)  Thrombosis  of  a  dilated  vein  may  occur 
independently  of  or  associated  with  infection  of  a  hemorrhoid, 
forming  a  hard,  extremely  painful  tumor.  An  ice-bag,  cold 
compresses,  or  opium  suppositories  may  give  temporary  relief, 
but  surgical  incision,  with  the  evacuation  of  a  septic  thrombus, 
is  usually  necessary.  (6)  Perirectal  abscess  may  originate  from 
an  infected  hemorrhoid. 

The  complaint  of  hemorrhoids,  or  "piles,"  is  a  common 
one,  and  in  all  cases  thorough  examination  is  indicated  to  exclude 
the  presence  of  a  serious  lesion,  particularly  cancer  of  the  rec- 
tum or  sigmoid. 

Principles  of  Treatment. — (1)  Palliative,  relief  of  constipa- 
tion by  diet,  mineral  oil,  or  drugs,  to  secure  soft,  semi-fluid 
evacuations  and  prevent  straining.  Local  treatment  of  fissure 
or  thrombosed  hemorrhoids  is  indicated,  since  these  tend  to 
produce  constipation  on  account  of  pain.  Rest  in  bed  and  local 
applications  after  bowel  movement  may  be  necessary  to  pre- 
vent congestion  and  protrusion  of  hemorrhoids.  Local  salves 
and  applications  greatly  relieve  distressing  symptoms,  but 
rarely  effect  a  cure.  However,  these  with  correction  of  causal 
factors  will  do  much  to  render  the  condition  endurable,  (2) 
Radical  cure  by  operation  represents  the  method  of  choice  in 


THE  GASTRO-INTESTINAL  ORGANS  191 

persisting  cases  or  where  there  are  comphcations,  especially 
bleeding.  Simple  cases  may  be  done  under  local  anaesthesia 
with  comparatively  little  discomfort,  but  extensive  involve- 
ment usually  requires  general  ansesthesia.  Various  types  of 
operations  are  indicated  for  special  cases  or  are  selected  by 
individual  surgeons.  Careful  after-treatment  is  necessary  to 
overcome  constipation  or  other  predisposing  cause  and  pre- 
vent recurrence. 

D.  Cancer  of  the  rectum.  Next  to  the  stomach,  the  rec- 
tum is  the  most  frequent  site  of  malignant  disease  of  the  gas- 
tro-intestinal  tract.  Many  of  the  cases  are  mistaken  for  hem- 
orrhoids till  proctoscopic  examination  shows  an  advanced 
lesion.  Effects  are :  Local  pain,  especially  at  defecation,  blood, 
mucus,  or  pus  in  the  stools,  constriction  of  the  rectum  with 
ribbon  stools.  The  diagnosis  is  usually  made  by  rectal  and 
proctoscopic  examination.  Prompt  radical  operation  is  indi- 
cated, and,  if  done  early,  offers  a  reasonably  good  prognosis, 
since  metastases  occur  comparatively  late  in  the  course  of  the 
disease.  When  these  are  found  in  the  liver,  the  prognosis  is 
hopeless.  Operation  consists  of  complete  excision  of  the  rectum 
involved:  (1)  Through  the  perineum,  and  the  sigmoid  above  is 
brought  down  to  the  surface  at  the  anus.  (2)  By  a  prelim- 
inary abdominal  operation  to  exclude  the  presence  of  metas- 
tases, and  possibly  to  establish  an  artificial  anus,  followed  by 
excision  of  the  rectum  through  the  perineum.  In  order  to  secure 
complete  removal  of  the  new-growth,  it  is  often  necessary  to 
estabhsh  a  permanent  fecal  fistula  by  colostomy.  Such  a  pro- 
cedure allows  more  radical  removal  of  the  cancer  and  gives 
greater  security  against  recurrence.  A  properly  arranged  col- 
ostomy can  be  made  with  a  perfect  sphincter  permitting  of  reg- 
ular bowel  movements  and  no  soihng.  It  may  be  accepted 
by  the  patient  "wdth  assurance  that  there  wall  be  very  httle 
inconvenience. 

The  Vermiform  Appendix. — (Fig.  41.  See  Anatomy  and 
Physiology.)  This  organ  represents  a  direct  continuation  of 
the  cecum,  which  it  resembles  in  structure,  and  has  its  own 
mesentery  carrying  the  blood  and  lymph  vessels.  The  wall 
is  imusually  rich  in  lymphatic  structure,  while  the  lumen  is 
lined  with  columnar  epithelium,  and  normally  is  patent.  Con- 
genital or  inflammatory  constriction  may  cause:  (1)  Stasis  of 


192       ESSENTIALS  OF  SURGERY  FOR  NURSES 


contents  in  the  lumen,  resulting  in  "appendiceal  coli," 
due  to  peristaltic  efforts  to  empty  itself,  or  (2)  the  formation 
of  fecal  concretions,  "fecoliths,"  and  a  tendency  to  local 
inflammation. 

Surgical  lesions  of  the  appendix  include: 


A.  Inflammations 

B.  Tumors 


fa.  Catarrhal. 
1 


1.  Acute -jb.  Suppurative. 
[c.  Perforations. 

2.  Chronic  appendicitis. 

{1.  Mucocele. 
2.  Cancer. 


COiOAf 


C£C(/Af 


'/L£Ur^ 


y/iii^£ 


-/iPP£NO/X 


I  om/w/?//v/7i  /sm^j 


Fig.  41. — Colon,  ileo-cecal  region,  and  appendix. 

A.  Inflammations  of  the  appendix  represent  the  most  com- 
mon acute  surgical  lesion  of  the  abdomen  and  are  described 
clinically  under  several  more  or  less  distinct  forms,  which  are  all 
different  stages  of  an  inflammatory  lesion.  All  acute  attacks 
are  associated  with  severe  abdominal  pain,  vomiting,  local 
tenderness,  and  muscle  rigidity  in  the  right  ihac  region,  and 
usually  with  fever  and  leucocytosis.  Recognition  of  the  exact 
pathological  change  in  the  appendix,  or  prediction  of  the  prob- 
able outcome  from  cHnical  observation,  is  rarely  possible  with 
any  degree  of  certainty.  Therefore  most  surgeons  advise  im- 
mediate operation  as  early  as  a  diagnosis  of  acute  appendicitis  is 


THE  GASTRO-INTESTINAL  ORGANS  193 

made.  Simple  cases  often  progress  rapidly  and  develop  serious, 
if  not  fatal,  complications  while  under  careful  observation,  with 
surprisingly  little  clinical  evidence.  This  is  particularly  true  if 
the  pain,  which  is  the  best  indication  of  serious  disturbance,  is 
masked  by  morphine,  or  if  fluids  or  cathartics  have  been  given 
by  mouth,  stimulating  peristalsis  and  interfering  with  nature's 
attempt  to  hmit  the  infection. 

Types. — (1)  Acute  catarrhal  appendicitis  consists  of  acute 
inflammatory  changes  in  the  lumen  or  wall  of  the  appendix,  but 
with  no  actual  suppuration  or  pus  formation.  Possible  effects 
are:  (a)  Changes  in  the  structure  of  the  appendix  which  pre- 
dispose to  further  trouble;  (6)  rapid  progress  to  the  stage  of 
suppuration.  The  clinical  evidences  are  usually  comparatively 
mild  and  subside  within  a  few  days.  Light  attacks  are  often 
unrecognized,  or  are  not  sufficiently  severe  to  call  a  physician. 
However,  they  are  important  in  the  history  of  cases  where  there 
is  subsequent  disturbance  suggesting  a  lesion  of  the  appendix. 

(2)  Acute  suppurating  appendicitis  is  characterized  by  de- 
struction of  tissue  and  the  formation  of  pus  in  the  wall  or  lumen 
of  the  appendix.  Results:  Under  favorable  circumstances  the 
condition  may  be  self-hmited  even  at  this  stage,  but  permanent 
changes  in  the  organ  occur,  leading  to  chronic  or  recurring 
gastro-intestinal  disturbances,  known  clinically  as  "chronic 
appendicitis."  The  more  frequent  outcome  is  rapid  progress  to 
the  gangrenous  destruction  of  the  wall,  and 

(3)  Perforating  appendicitis,  with  local  or  general  peritonitis. 
Clinical  evidences  of  suppurating  appendicitis  include  persist- 
ence of  pain,  nausea  and  vomiting,  marked  local  tenderness 
and  muscle  resistance,  increase  in  fever,  pulse-rate  and  leuco- 
cytosis. 

Complications  and  Dangers. — Gangrenous  perforation  of  the 
appendix  and  extension  of  the  infection  to  the  peritoneal  cavity. 

The  most  favorable  forms  of  this  extension  occur :  (a)  When 
the  appendix  Hes  in  certain  positions.  Example,  outside  of  the 
cecum,  where  the  septic  material  is  localized  by  natural  sur- 
roundings and  is  soon  walled  off  by  protective  adhesions,  forming 
a  locahzed  abscess.  (6)  The  infection  extends  gradually,  and 
protective  adhesions  of  the  omentum  develop  rapidly,  thus 
limiting  the  process  to  a  definitely  locahzed  area.  In  either  case 
the  process  is  a  conservative  one,  and  the  protective  adhesions 
13 


194       ESSENTIALS  OF  SURGERY  FOR  NURSES 

represent  an  attempt  to  encapsulate  and  localize  the  septic 
area.  If  this  be  undisturbed  by  excessive  peristalsis  induced  by 
food  or  cathartics,  there  will  develop  a  well-localized  abscess 
which  can  be  treated  surgically  by  incision  and  drainage.  Ex- 
tension and  general  peritonitis  may  develop  spontaneously,  as 
a  result  of  active  peristalsis,  or  by  unwise  operative  manipula- 
tions, with  disastrous  results. 

The  more  unfavorable  form  of  extension  occurs:  (a)  When 
there  is  sudden  rupture  of  a  gangrenous  appendix  and  the  sep- 
tic material  reaches  the  free  peritoneal  cavity  in  such  a  manner 
that  there  is  no  possibility  of  limiting  the  process  by  protective 
adhesions.  This  may  also  occur  from  breaking  down  and  exten- 
sion of  a  localized  abscess.  A  general  diffuse  peritonitis  results, 
due  to  virulent  organisms,  and  renders  the  prognosis  more  unfa- 
vorable. (6)  Late  complications  in  neglected  cases  or  in  in- 
stances where  localized  abscesses  are  incompletely  drained 
include:  (i)  Perinephritic  or  pelvic  abscesses  due  to  the  collec- 
tion of  septic  material  by  gravity,  (ii)  Liver  abscess  due  to 
the  extension  of  the  sepsis  through  the  portal  veins  or  lymphatics 
(see  p.  199.)  (iii)  General  pyaemia,  or  continued  sepsis,  due  to 
unrecognized  or  inaccessible  foci  of  infection. 

Principles  of  Treatment. — 1.  Palliative  measures.  It  is  to  be 
understood  that  acute  appendicitis  is  essentially  a  surgical 
lesion,  and  only  in  certain  exceptions  is  it  justifiable  to  delay 
suitable  operation.  These  exceptions  include:  (a)  Early  cases 
where  a  reasonable  diagnosis  is  not  possible.  (6)  Certain  late  or 
neglected  cases  where  a  localized  peritonitis  is  evidently  being 
walled  off,  and  surgical  judgment  indicates  delay  till  a  local 
appendiceal  abscess  can  be  more  safely  opened  and  drained, 
(c)  Very  mild  attacks  or  instances  where  surgical  relief  is  not 
accessible  are  often  carried  over  the  acute  attack,  and  elective 
appendectomy  performed  later.  In  all  such  cases,  the  most 
important  consideration  is  that  nothing  be  done  to  aggravate 
the  condition,  or  to  mask  significant  symptoms  which  indicate 
serious  extension  or  complications,  as  peritonitis.    (See  p.  169.) 

Cathartics  by  mouth  are  most  dangerous  and  should  be 
withheld  in  all  suspicious  cases.  It  has  been  said  that  all  cases 
which  develop  fatal  peritonitis  have  received  cathartics  early 
in  the  attack.  Fluids  by  mouth  are  also  contraindicated  on 
the  same  basis  on  account  of  acute  peristalsis.     Morphine  for 


THE  GASTRO-INTESTINAL  ORGANS  195 

pain  is  to  be  used  only  on  the  direct  order  of  the  surgeon,  and 
preferably  only  after  a  diagnosis  has  been  made  and  operation 
arranged.  Otherwise  the  condition  is  best  handled  on  the 
principles  outlined  for  beginning  peritonitis.    (See  p.  169). 

Mild  attacks  are  frequently  carried  over  the  acute  stage 
and  subside  spontaneously,  but  it  is  never  possible  for  the  sur- 
geon to  estimate  accurately  the  pathological  changes  which  have 
already  taken  place,  or  to  predict  the  probable  outcome  with 
any  degree  of  certainty.  Many  cases  which  recover  the  primary 
attack  are  left  with  a  permanently  damaged  appendix  which 
gives  rise  to  recurrent  disturbance,  or  later,  to  more  serious 
attacks. 

2.  Surgical  Measures. — (a)  Simple  appendectomy  is  usually 
possible  in  the  early  cases  where  the  infection  is  limited  to  the 
lumen  or  wall  of  the  appendix.  This  should  be  followed  by  an 
uncomplicated  convalescence,  and  the  laparotomy  wound  should 
heal  by  first  intention,  (h)  Drainage  of  locaUzed  abscesses  is 
necessary  in  cases  which  are  seen  later  after  the  process  has  ex- 
tended to  the  peritoneum,  at  which  time  the  appendix  is  removed 
if  this  be  reasonably  possible.  At  this  stage  the  essential  lesion 
is  a  localized  peritonitis  which  must  be  effectually  drained, 
while  the  diseased  appendix  may  be  inaccessible,  and  therefore 
is  left  for  a  subsequent  operation.  If  drainage  is  successful  the 
condition  should  improve  progressively.  Persistence  or  recur- 
rence of  toxic  sjTnptoms  is  evidence  that  drainage  is  ineffective, 
or  that  other  foci  of  infection  are  present  and  not  draining,  (c) 
Advanced  cases  with  general  peritonitis  are  treated  on  prin- 
ciples already  outlined.  (See  p.  170).  (d)  Interval  appendec- 
tomy between  attacks  may  be  indicated :  (i)  Patients  who  have 
had  one  or  more  definite  acute  attacks  of  appendicitis,  (ii)  The 
"chronic  appendix."  (iii)  When  the  abdomen  is  opened  for 
other  purposes  and  the  condition  of  the  patient  does  not  contra- 
indicate  the  slight  added  procedure. 

Post-operative  complications  of  special  interest: 

1.  Continued  sepsis  and  fever  may  be  due  to:  (a)  Un- 
recognized foci  of  infection;  (6)  imperfect  drainage;  (c)  wound 
infection.  It  calls  for  careful  examination  by  the  surgeon,  pos- 
sibly rearrangement  of  the  drainage,  further  exploration  of  the 
wound,  special  positions  (Fowler's),  proctoclysis,  and  general 
treatment. 


196       ESSENTIALS  OF  SURGERY  FOR  NURSES 

2,  Fecal  fistula,  due  to  sloughing  through  the  cecum  into 
the  laparotomy  wound,  may  occur  during  the  first  few  days 
after  operation,  accompanied  by  profuse  fecal  discharge.  Spon- 
taneous closure  is  the  rule  within  a  few  weeks  unless  there  is 
obstruction  of  the  colon,  or  the  wound  is  kept  open  by  drainage. 

3.  Post-operative  hernia  from  incomplete  healing  of  a 
wound  which  has  been  drained  is  not  uncommon. 

'^Chronic  appendicitis"  is  a  term  applied  to  a  variety  of 
remote  gastro-intestinal  disturbances,  but  should  be  limited  to 
cases  showing  actual  pathological  change  in  the  appendix,  usu- 
ally the  result  of  inflammation. 

Clinical  evidence  may  be:  (a)  Repeated  mild  attacks  sug- 
gesting acute  appendicitis.  (6)  Recurrent  gastro-intestinal  dis- 
turbance associated  with  pain  and  tenderness  in  the  right  iliac 
region.  An  exact  diagnosis  is  not  always  possible,  but  explora- 
tory laparotomy  is  indicated  in  persistent  cases.  Pathological 
changes  in  the  appendix,  adhesions,  constriction,  thickening  of 
the  wall,  or  fecal  concretions  confirm  the  diagnosis.  At  all  such 
exploratory  operations  the  surgeon  usually  examines  the  pelvic 
structures,  ureter,  gall-bladder,  and  stomach,  to  exclude  such 
other  possible  lesions  which  might  cause  similar  symptoms. 
Many  cases  of  so-called  chronic  appendicitis  are  really  due  to 
such  lesions,  and  simple  appendectomy  naturally  gives  no  rehef . 

B.  Tumors  of  the  appendix  include:  1.  Cysts,  usually  due 
to  the  retention  of  secretion,  caused  by  constriction  at  the  base. 

2.  Cancer  of  the  appendix  is  an  occasional  finding  at  opera- 
tion. There  are  no  characteristic  symptoms  by  which  such  a 
lesion  can  be  recognized  clinically.  Local  pain,  tenderness,  and 
gastro-intestinal  disturbance  will  suggest  some  lesion  in  this 
region,  but  the  condition  is  often  discovered  at  exploratory 
laparotomy  or  abdominal  operation  for  other  cause. 

DEMONSTRATIONS 

1.  Demonstration  of  gastro-intestinal  tract,  anatomical  chart. 

2.  Histories,  cases  of  acute  gastritis  with  explanation  of  causes. 

3.  Histories  of  cases  of  chronic  indigestion. 

4.  Case  history  of  congenital  pyloric  stenosis,  with  illustration. 

5.  X-ray  pictures:   hour-glass  stomach,  and  pyloric  obstruction. 

6.  X-ray  picture  showing  foreign  body  in  the  stomach. 

7.  History  of  gastric  ulcer  with  complications. 

8.  Laboratory  test  demonstrating  "occult  blood." 

9.  Methods  of  treating  hemorrhage  from  gastric  ulcer. 
10.  History  of  case  of  ruptured  gastric  ulcer. 


THE  GASTRO-INTESTINAL  ORGANS  197 

11.  Statistics  showing  relation  of  gastric  ulcer  to  gastric  cancer. 

12.  Study  of  diet  lists  and  medical  treatment  of  gastric  ulcer. 

13.  Statistics  showing  results  of  early  and  late  operation  for  cancer. 

14.  Case  histories  of  various  types  of  intestinal  obstruction. 

15.  Figures  showing  results  of  early  and  late  operation  for  obstruction. 

16.  X-ray  plates  showing  partial  obstruction,  and  malposition  of  the  colon. 

17.  Case  history  of  post-operative  fecal  fistula,  demonstration  of  apparatus 

and  dressings  for  care  of  colostomy  for  cancer  of  rectum. 

18.  X-ray  plates  showing  diverticuliun  of  sigmoid,  also  of  perirectal  abscess 

iajected  with  bismuth. 

19.  Demonstration,  proctoscopic  examination,  showing  ulcers,  polyps,  etc. 

20.  Case  demonstration,  "fistulo  in  ano." 

21.  Cases  of  hemorrhoids,  local  treatments  and  apphcations. 

22.  Case    histories    and    charts    showing    types    of    appendicitis    and 

complications. 


CHAPTER  XIII 
THE  LIVER,  BILE  PASSAGES,  PANCREAS,  AND  SPLEEN 

The  Liver. — (A)  Anatomical  and  physiological  consider- 
ations: (1)  Portal  circulation,  obstruction;  (2)  lymphatic 
drainage  and  infections;  (3)  relations.  (B)  Surgical  lesions: 
(1)  Wounds;  (2)  abscess;  (3)  cancer;  (4)  gumma. 

The  liver  is  a  glandular  structure  located  in  the  right  hypo- 
chondrium  and  epigastrium.  Through  the  portal  circulation  it 
receives  various  substances  absorbed  from  the  gastro-intestinal 
tract,  and  plays  an  important  role  in  the  assimilation  of  car- 
bohydrates and  proteids.  Its  principal  external  secretion,  the 
bile,  is  formed  from  the  blood  in  the  liver  cells,  and  carried 
through  the  bile-ducts  to  the  intestinal  tract.  Disturbances  in 
function  of  the  liver  cause  more  or  less  definite  constitutional 
and  metabolic  results,  and  may  give  rise  to  serious  post-operative 
complications:  acidosis,  post-operative  vomiting,  or  late  chlo- 
roform poisoning. 

A.  Anatomical  and  Surgical  Relations. — 1.  The  portal 
circulation  receives  the  blood  from  the  entire  gastro-intestinal 
tract,  pancreas,  and  spleen.  Obstruction  of  the  portal  vein  or 
capillaries  in  the  liver  results  in  stasis  of  blood  in  the  intestinal 
tract  and  peritoneum. 

Causes. — (a)  Passive  congestion  of  the  liver  due  to  "broken 
compensation  of  the  heart."  (&)  Cirrhosis  of  the  liver,  a  patho- 
logical condition  characterized  by  development  of  fibrous  tissue 
about  the  portal  capillaries  and  intei^'ference  with  the  portal 
circulation,  (c)  Pressure  of  tumors  or  new-growths  on  the 
portal  vein. 

Results. — (a)  Stasis  of  blood  in  the  gastric  and  mesenteric 
veins.  (6)  Ascites,  collection  of  free  fluid  in  the  peritoneal  cav- 
ity, (c)  Development  of  collateral  circulation  between  branches 
of  the  portal  veins  and  certain  systemic  veins,  establishing  a 
partial  compensation:  (i)  At  the  cardiac  end  of  the  stomach, 
(ii)  Between  the  superior  and  middle  hemorrhoidals,  (iii)  Su- 
perficial abdominal,  epigastric,  and  hypogastric  veins  with  the 
deep  vessels.  Such  veins  become  dilated  and  varicose  and  may 
198 


THE  LIVER  199 

rupture  with  serious  hemorrhage,  or  persist  as  varicosities  or 
hemorrhoids.  Principles  of  Treatment  (see  Ascites,  p.  167), — 
Medical  treatment  of  the  causal  conditions  is  indicated.  "Tap- 
ping" with  a  trocar  under  aseptic  precautions  gives  temporary- 
relief,  but  the  fluid  rapidly  re-accumulates.  Radical  operations 
have  been  suggested,  which  attempt  to  form  an  anastomosis 
between  the  portal  vein  and  inferior  vena-cava,  or  between 
the  omental  vessels  and  systemic  circulation. 

2.  The  portal  vein  carrying  venous  blood  from  the  gastro- 
intestinal tract,  pancreas,  and  liver,  and  the  lymphatic  vessels 
from  these  regions,  pass  through  the  liver.  Therefore  sepsis  or 
malignant  disease  of  these  organs  is  followed  eventually  by 
secondary  foci;  abscess,  or  cancer  in  the  liver. 

3.  The  upper  surface  of  the  liver  lies  in  immediate  contact 
with  the  diaphragm.  Therefore  liver  abscess  may  extend, 
resulting  in  empyema  of  the  pleural  cavity,  or  infection  of  the 
mediastinum. 

B.  Surgical  lesions  of  the  liver  include:  (1)  Wounds,  (2) 
abscess,  (3)  cancer,  (4)  gumma. 

1.  Wounds. — Stab- wounds  or  traumatic  rupture  are  asso- 
ciated with  free  hemorrhage  into  the  peritoneum.  Repair  of 
wounds  of  the  liver  is  exceedingly  difficult,  since  sutures  cut 
through  the  friable  liver  substance. 

2.  Abscess  is  usually  secondary  to  infections  in  the  area 
tributary  to  the  portal  circulation  or  lymphatic  drainage. 
Example,  appendicitis.  There  may  be  a  single  large  abscess,  or 
a  number  of  smaller  ones  scattered  through  the  hver  substance. 
Evidences  of  liver  abscess :  Continued  fever  and  sepsis,  enlarged 
liver,  and  local  tenderness.  Clinical  recognition  of  the  condition 
is  often  difficult.  Significance  and  prognosis:  A  single  abscess, 
accessible  to  surgical  drainage  and  promptly  treated,  commonly 
heals  completely,  but  multiple  abscesses  indicate  low  general 
resistance,  often  being  accompanied  by  pyaemia  and  metastatic 
abscesses  in  other  parts  of  the  body,  so  that  surgical  treatment 
is  out  of  the  question. 

Principles  of  Treatment. — (a)  The  original  lesion  (example, 
appendix  abscess)  is  to  be  opened  and  drained.  (6)  A  large, 
single  liver  abscess  can  usually  be  successfully  evacuated  and 
drained.  Multiple  abscesses  are  not  all  accessible,  and  indicate 
a  hopeless  pyaemia. 


200       ESSENTIALS  OF  SURGERY  FOR  NURSES 

3.  Cancer  of  the  liver  is  rarely  primary  in  that  organ.  It  is 
usually  present  as  multiple  nodules  which  are  metastases  from 
a  primary  growth  in  other  organs,  intestinal  tract,  or  perito- 
neal cavity.  The  finding  of  such  multiple  nodules  in  the  liver  at 
exploratory  operation  is  conclusive  evidence  that  the  original 
growth  is  inoperable. 

4.  Gumma  of  the  liver,  due  to  syphilis,  causes  constitutional 
evidence  of  the  disease,  and  irregular  enlargement  of  the  liver, 
or  localized  tumor  formation.  It  is  not  a  surgical  condition  but 
may  be  mistaken  for  abscess  or  new-growth.  Special  anti- 
syphilitic  treatment  is  followed  by  definite  improvement. 

The  Bile  passages  (see  Fig.  42)  include:  the  hepatic  duct, 
cystic  duct,  gall-bladder  and  common  bile  duct,  which  opens  in 
connection  with  the  pancreatic  duct,  into  the  duodenum  at  the 
diverticulum  of  Vater.  The  bile  is  secreted  in  the  liver  cells, 
collected  by  the  bile  capillaries,  and  passes  into  the  hepatic 
duct.  The  cystic  duct  and  gall-bladder  serve  two  functions: 
(a)  As  a  reservoir  where  the  bile  is  stored  and  emptied  into  the 
common  bile-duct  and  duodenum,  in  response  to  certain  stimuli. 
(6)  The  mucous  membrane  of  the  gall-bladder  secretes  mucous 
and  substances  giving  the  bile  its  normal  consistency,  and  hold- 
ing the  cholesterin  and  bile-salts  in  solution.  The  common 
bile-duct  opens  into  the  duodenum  at  the  diverticulum  or 
ampulla  of  Vater,  m  common  with  the  pancreatic  duct.  (See 
Fig.  42.)  This  relationship  is  unportant,  since  occlusion  of  the 
intestinal  opening  may  result  in  the  regurgitation  of  normal  or 
infected  bile  into  the  pancreas,  causing  lesions  of  that  organ. 
The  common  bile-duct  passes  in  close  relation  to  the  head  of  the 
pancreas,  and  may  be  obstructed  by  tumors  or  enlargements  of 
that  organ. 

"Jaundice"  or  "icterus"  is  one  of  the  most  important  clinical 
conditions  associated  with  lesions  of  the  bile-passages.  It  is  due 
to  retention  within  the  liver  of  the  "bile  pigments"  which  are 
normally  excreted  in  the  bile  and  carried  to  the  intestinal  tract. 
Under  certain  pathological  conditions,  these  substances  are 
retained  in  the  liver  cells,  taken  up  by  the  systemic  circulation, 
and  deposited  in  various  tissues  of  the  body. 

Causes. — 1.  Obstruction  of  the  common  bile-duct  or  hepatic 
duct  by:  (a)  Inflammatory  swelling  in  connection  with  similar 
conditions   in  the  intestinal  tract.     "Catarrhal  jaundice"  is 


THE  BILE  PASSAGES 


201 


gradual  in  development  and  subsides  spontaneously  as  the  under- 
lying condition  clears.  (6)  Obstruction  of  the  common  duct  by 
stone,  usually  preceded  by  evidence  of  gall-stones  in  the  gall- 
bladder or  cystic  duct.  Complete  obstruction  of  the  cormnon 
duct  by  stone  is  rarely  of  long  standing,  but  the  jaundice  will 
recur  intermittently  till  the  calculus  is  removed  or  passed  into 
the  duodenum.    A  calculus  in  the  ampulla  of  Vater  is  character- 


GALL  BLADDEfi 


W6HT/IND  LEFT  H£P/IT/CDUCr 


CYST/CDUCr^ 


DOODEAfi/M 


PAP/ll./i  OF 
VATFff 


DUOD£W/i 


p/!NCF£/ir/c  /?ucr 

Fig.  42. — Relations  of  bile-passages,  duodenum,  and  head  of  pancreas. 

ized  by  intermittent  jaundice  and  possibly  chills  or  sepsis,  (c) 
External  pressure  by  tumors  or  growths,  particularly  in  the 
head  of  the  pancreas,  results  in  persistent  jaundice  of  the  most 
extreme  type. 

2.  Certain  types  of  cirrhosis  of  the  liver  and  other  forms  of 
constitutional  disease  are  less  common  causes  of  persistent 
jaundice. 

Evidences  and  Effects. — 1.  Pigmentation  of  the  skin,  at  first 
a  light  yellow,  later  a  bright  lemon  color,  and  finally  an  olive 
green,  in  long-standing  cases. 


202       ESSENTIALS  OF  SURGERY  FOR  NURSES 

2.  Pigmentation  of  the  sclerotic  coat  of  the  eye  is  often  an 
early  sign  of  beginning  jaundice. 

3.  Clay  colored  stools,  due  to  the  absence  of  bile  pigments 
in  the  intestinal  tract. 

4.  High  colored  urine  from  the  presence  of  bile  pigments 
excreted  from  the  circulating  blood  by  the  kidneys. 

5.  "Pruritis,"  persistent  itching,  is  usually  present. 

6.  "Cholsemia,"  changes  in  the  blood  due  to  the  retention 
of  bile  retarding  the  coagulation  time  and  predisposing  to  per- 
sistent hemorrhage,  which  is  not  easily  controlled.  This  may 
contraindicate  surgical  operation  till  the  condition  is  corrected 
by  proper  treatment. 

Jaundice,  either  present  or  remote,  is  always  an  important 
sjrmptom  in  the  recognition  of  lesions  of  the  bile  passages. 
Treatment  is  directed  at  the  underlying  condition,  in  any  case. 

Surgical  lesions  of  the  gall-bladder  and  bile-ducts  include: 
(A)  Infections,  "cholecystitis;"  (B)  "gall-stones,"  choleli- 
thiasis; (C)  cancer. 

A.  Infections. — 1.  Acute  cholecystitis,  involving  the  mucous 
membrane  of  the  gall-bladder,  is  secondary  to  more  or  less  re- 
mote inflammatory  lesions  of  other  structures,  particularly  the 
intestinal  tract.  (Examples:  typhoid,  appendicitis.)  The  onset 
is  sudden  with :  (a)  Evidences  of  sepsis,  fever,  and  leucocytosis. 
(6)  Abdominal  pain,  local  tenderness,  and  muscle  rigidity,  (c) 
Gastro-intestinal  symptoms,  nausea,  and  vomiting.  The  course 
is  progressive,  but  usually  subsides  in  one  or  two  weeks. 

Complications  are:  (a)  Severe  sepsis  and  toxaemia.  (6) 
Perforation  of  the  gall-bladder,  resulting  in:  (i)  Local  adhesions 
and  persistent  disturbance,  (ii)  Sudden  rupture  and  severe 
general  peritonitis,  (c)  Permanent  inflammatory  changes  in 
the  gall-bladder  or  cystic  duct  resulting  in  stasis  of  bile,  re- 
current attacks  of  subacute  cholecystitis,  or  formation  of  gall- 
stones. 

Principles  of  Treatment. — During  the  acute  attack  this  is 
usually  limited  to  palliative  measures,  operation  being  reserved 
for  a  later  stage,  except  in  the  presence  of  certain  conditions: 
severe  sepsis  or  perforation  and  general  peritonitis.  Palliative 
treatment  includes:  Rest  in  bed,  ice-bag  locally,  limitation  of 
foods  and  fluids  by  mouth,  especially  in  case  of  nausea  and 
vomiting,  and  certain  medicines  as  ordered.     Surgical  treat- 


THE  BILE  PASSAGES  203 

ment  may  be  indicated  as  follows:  (a)  Cholecystostomy,  tem- 
porary drainage  of  the  gall-bladder.  (6)  Laparotomy  and 
drainage  of  a  general  peritonitis  as  an  emergency  operation 
in  case  of  rupture  of  a  distended  septic  gall-bladder,  (c)  Chole- 
cystectomy, removal  of  a  damaged  gall-bladder,  usually  after 
the  acute  attack  has  passed. 

2.  Chronic  cholecystitis  associated  with  inflammatory 
changes  in  the  gall-bladder  is  not  infrequent  following  an  acute 
attack,  and  also  occurs  in  cases  where  there  is  no  definite  history 
of  a  previous  acute  process.  Chronic  cholecystitis  may  present  a 
variety  of  clinical  symptoms:  (a)  Recurrent  attacks  of  local 
pain,  abdominal  distress,  and  subacute  symptoms.  (6)  Chronic 
or  recurrent  gastro-intestinal  disturbances  characterized  by 
gaseous  indigestion,  pain  after  eating,  especially  after  eating 
certain  foods  (fats),  and  constipation,  (c)  Evidences  of  ''chole- 
lithiasis," recurrent  attacks  of  gall-stone  cohc,  which  is  a  sig- 
nificant   indication  of    chronic    trouble    in    the    gall-bladder. 

(d)  Recurrent  attacks  of  fever  and  sepsis  of  obscure  origin. 

(e)  Remote  constitutional  symptoms  or  metabolic  disturbances 
due  to  a  secondary  effect  on  the  pancreas. 

Principles  of  Treatment. — General  or  medical  treatment,  with 
dietary  restrictions,  is  indicated  during  an  acute  process,  but 
has  little  curative  influence  when  there  is  organic  change  in  the 
gall-bladder  or  bile-passages.  Surgery  is  indicated:  (a)  To  re- 
lieve chronic  or  recurrent  disturbance.  (6)  In  obscure  cases  to 
establish  a  diagnosis,  relieve  the  cause,  and  exclude  cancer. 
Operation  consists  of:  (i)  Cholecystostomy  and  drainage,  or 
(ii)  cholecystectomy  in  certain  cases. 

B.  Cholelithiasis. — "Gall-stones"  consist  of  concretions 
or  calculi  of  bile  salts  and  cholesterin  which  are  normally  held  in 
solution  by  the  bile,  but  under  certain  conditions  are  deposited 
in  the  gall-bladder. 

Predisposing  causes :  Infection  of  the  gall-bladder,  resulting 
in  destruction  of  mucous  membrane,  or  constriction  of  the 
cystic  duct,  causing  stasis  of  bile.  It  happens  not  infrequently 
that  the  preceding  cholecystitis  is  remote  or  indefinite,  and  is 
evident  only  as  recurrent  gastro-intestinal  disturbances.  Evi- 
dences :  Gall-stones  in  the  gall-bladder  cause  only  s5miptoms  of 
cholecystitis.  Acute  "gall-stone  colic"  is  due  to  the  passage  of 
calculi  through  the  narrow  bile-ducts.    The  attack  comes  on 


204       ESSENTIALS  OF  SURGERY  FOR  NURSES 

suddenly  without  immediate  warning  or  premonitory  symptom 
other  than  indigestion.  The  cohc  is  characterized  by  acute 
stabbing  pain  under  the  right  costal  margin,  usually  radiating 
to  the  right  shoulder.  The  duration  is  variable,  a  few  hours, 
passing  when  the  calculus  reaches  the  duodenum.  In  case  it 
lodges  in  the  duct,  the  acute  colic  passes  off  to  be  followed  by 
persistent  local  tenderness  and  distress.  There  may  be  dilata- 
tion of  the  gall-bladder,  jaundice  or  cholecystitis,  if  the  ducts 
are  occluded  by  a  calculus.  Other  symptoms  include  pros- 
tration, nausea,  and  vomiting,  but  no  fever  or  sepsis  unless  there 
is  cholecystitis. 

After  effects :  (a)  Recurrent  attacks  are  common  since  there 
are  usually  chronic  changes  in  the  gall-bladder,  predisposing  to 
the  formation  of  calculi  though  months  or  years  may  intervene. 
(h)  Chronic  cholecystitis  is  commonly  present,  (c)  Destruc- 
tion of  the  gall-bladder  and  ulceration  of  a  stone  into  the  intes- 
tinal tract  occurs  in  rare  instances,  (d)  Lodging  of  a  stone  in 
the  common  duct,  or  diverticulum  of  Vater,  with  intermit- 
tent jaundice  and  cholecystitis,  (e)  Regurgitation  of  bile  into 
the  substance  of  the  pancreas  and  serious  lesions  of  that 
organ.  (/)  Cancer  of  the  gall-bladder  or  ducts,  due  to  persistent 
irritation. 

Principles  of  Treatment. — ^(1)  Acute  colic.  Treatment  is  usu- 
ally limited  to  relief  of  pain  by  efficient  doses  of  morphine  hy- 
podermically,  till  the  stone  is  passed  into  the  duodenum.  (2) 
Surgical  treatment  may  be  indicated :  (a)  In  cases  where  there 
have  been  one  or  more  acute  attacks  of  colic,  which  is  accepted 
as  evidence  of  a  lesion  of  the  gall-bladder,  (h)  When  a  stone  has 
lodged  in  the  cystic  or  common  duct.  Operation  will  consist  of: 
(a)  Removal  of  the  stone,  usually  with  drainage  of  the  gall- 
bladder, (b)  Cholecystectomy  when  indicated  by  permanent 
damage  to  the  gall-bladder,  (c)  Removal  of  stones  from  the 
cystic  or  common  duct,  which  is  a  more  complicated  procedure. 

C.  Cancer  of  the  gall-bladder  or  bile-ducts  is  compara- 
tively rare.  There  are  no  characteristic  symptoms  other  than 
evidence  of  a  serious  lesion  involving  the  bile-passages,  persist- 
ent local  pain  and  tenderness,  chronic  indigestion,  or  persistent 
jaundice  which  suggests  occlusion  of  the  bile-ducts,  often  from 
external  pressure  such  as  a  tumor  in  the  pancreas.  In  certain 
early  cases  complete  removal  is  possible,  but  metastases  are 


THE  PANCREAS  AND  SPLEEN  205 

frequently  found  in  the  liver,  at  the  exploratory  operation, 
which  finding  gives  a  hopeless  prognosis. 

The  Pancreas  is  a  glandular  structure  situated  behind  the 
stomach  in  the  epigastrium  and  left  hypochondrium. 

Practical  anatomical  relations  (see  Fig.  42,  p.  201) :  1.  The 
pancreatic  duct  opens  into  the  duodenum  with  the  common  bile- 
duct  in  the  ampulla,  or  diverticulum  of  Vater.  Obstruction  at 
this  point  by  stone  or  new-growth  may  result  in  a  regurgitation 
of  bile  into  the  substance  of  the  pancreas.  If  the  bile  is  actually 
septic,  there  often  results  an  acute  pancreatic  abscess,  or  hem- 
orrhagic pancreatitis.  In  other  cases  it  causes  a  chronic  pan- 
creatitis with  metabolic  and  constitutional  effects. 

2.  The  common  bile-duct  passes  in  close  relation  to  the  head 
of  the  pancreas  and  is  often  permanently  occluded  by  tumors  or 
cysts  of  that  structure,  resulting  in  a  persistent  high-grade 
jaundice. 

3.  Gastric  ulcer  perforating  the  posterior  wall  of  the  stomach 
may  extend  to  and  involve  the  substance  of  the  pancreas. 

Surgical  Lesions. — (1)  Acute  abscess,  or  ''hemorrhagic  pan- 
creatitis," is  sudden  in  onset,  characterized  by  most  severe 
abdominal  pain  and  prostration.  There  is  fever,  rapid  pulse,  and 
evidence  o^  profound  toxeemia  and  shock.  Rupture  to  the  free 
peritoneum  occurs  early  in  the  course,  usually  with  a  rapidly 
fatal  outcome.  Clinical  recognition  of  the  exact  condition  is  not 
always  possible,  but  the  picture  is  that  of  an  acute  abdominal 
emergency,  calling  for  prompt  surgical  treatment.  Adequate 
drainage  of  the  abscess  and  general  peritonitis  presents  the  only 
hope  of  successful  outcome.  (2)  Tumors,  cysts,  or  cancer 
present  no  characteristic  effects  except  those  due  to  pressure :  (a) 
A  deep  seated  mass  in  the  epigastrium,  (b)  Pressure  on  the  com- 
mon duct  and  jaundice  when  the  head  of  the  pancreas  is  in- 
volved. Cysts  may  often  be  successfully  enucleated,  but  cancer 
is  usually  inoperable. 

The  Spleen  is  located  in  the  left  hypochondrium,  behind 
and  above  the  fundus  of  the  stomach,  in  close  relation  to  the 
diaphragm  and  the  free  peritoneal  cavity.  Its  functions  are 
not  definitely  understood  but  are  associated  with  the  blood- 
forming  organs  during  embryonic  life  and  early  infancy.  In 
adult  life  the  spleen  is  involved  in  certain  diseases  of  the  blood- 
forming  organs:  bone-marrow  and  lymphatic  tissues. 


206       ESSENTIALS  OF  SURGERY  FOR  NURSES 

Surgical  lesions  include:  (A)  Rupture;  (B)  abscess;  (C) 
enlargements;  (D)  relation  to  blood  diseases. 

A.  Rupture  due  to  external  violence  may  occur  in  connection 
with  crushing  injury,  especially  when  the  spleen  is  enlarged  or  con- 
gested. Hemorrhage  is  profuse  and  may  be  fatal.  It  can  be 
controlled  only  by  prompt  laparotomy,  usually  with  splenectomy. 

B.  Abscess  of  the  spleen  may  complicate  certain  infectious 
diseases,  as  typhoid,  and  demand  surgical  rehef,  drainage,  or 
splenectomy.  Rupture  of  an  abscess  of  the  spleen  is  followed 
by  an  intense  diffuse  peritonitis,  for  which  surgical  treatment  is 
urgently  indicated. 

C.  Enlargements  of  the  spleen  may  be  due  to:  (o)  Acute 
general  infections  (typhoid),  usually  subsiding  spontaneously 
with  the  disease.  (6)  Malaria,  syphilis,  and  other  more  chronic 
infections,  in  which  case  the  enlargement  is  of  longer  duration, 
(c)  Circulatory  disturbances,  with  ''broken  compensations" 
of  the  heart  and  chronic  passive  congestion  in  connection  with 
a  similar  condition  of  the  liver,    (d)  Myelogenous  leukemia. 

In  these  four  conditions  the  splenic  enlargement  is  more  or 
less  compensatory,  and  treatment  is  usually  directed  towards 
the  underlying  cause,  (e)  Tumors  and  abscess  of  the  spleen 
are  rare,  but  splenectomy  may  be  indicated  in  certain  cases. 

D.  Certain  blood  diseases.  "Splenic  anaemia,"  Banti's  dis- 
ease, and  pernicious  anemia,  are  associated  with  characteristic 
pathological  changes  in  the  spleen  which  are  considered  by  some 
pathologists  as  causing  the  clinical  condition.  In  selected  cases 
splenectomy  is  done  and  is  followed  by  definite  improvement. 

DEMONSTRATIONS 

1.  Demonstration  of  collateral  circulation,  case  cirrhosis  of  the  liver. 

2.  History  and  temperature  chart  of  case  of  liver  abscess. 

3.  History  of  a  case  of  secondary  cancer  of  the  Uver  with  report  of  autopsy 

findings. 

4.  Case  of  jaundice  with  demonstration  of  pigementation,  skin  and  sclera. 

Demonstration  of  bile  in  the  urine  and  "clay-stools." 

5.  Cases  or  histories  of  jaundice  with  explanation  of  cause  and  result  of 

treatment. 

6.  History  of  case  of  acute  cholecystitis. 

7.  Histories  or  cases  of  chronic  cholecystitis  with  or  without  stones. 

8.  Demonstration  of  specimens  of  gall-stones.    Study  case  histories. 

9.  Case  histories  cancer  of  gall-bladder. 

10.  Case  histories:  acute  pancreatitis,  tumors  of  pancreas. 

11.  Case  showing  abdominal  tumor  enlarged  spleen,  from  any  cause. 

12.  Histories  showing  effect  of  splenectomy,  various  causes. 


CHAPTER  XIV 


THE  URINARY  TRACT:  KIDNEYS,  URETERS,  BLAD- 
DER,   URETHRA 

The  Kidneys. — (A)  Malformations,  displacements,  wounds. 
(B)    Infection,  acute  and  chronic.     (C)  Calculi.     (D)  Tumors. 

The  kidneys  are  located 
on  each  side  of  the  lower 
thoracic  and  upper  lumbar 
vertebrae,  surrounded  and 
supported  by  a  definite  fatty 
capsule.  (Fig.  43.)  The 
urine  is  secreted  through 
the  glomeruli  and  urinifer- 
ous  tubules  of  the  kidney 
substance,  and  carried  by  the 
various  collecting  tubules  to 
the  hilum  or  "pelvis"  of 
the  kidney.  (Fig.  44.)  The 
ureter  is  continuous  with 
the  pelvis  of  the  kidney  at 
its  lowest  point  so  that  nor- 
mally there  is  no  stasis  of 
urine,  though  this  is  a  fre- 
quent occurrence  in  patho- 
logical conditions. 

A.  MalformationSjDis- 

PLACEMENTS    AND  WoUNDS. 

— (1)  Congenital  anomaly  of 
shape  or  position  of  the  kid- 
neys is  comparatively  rare, 
but  may  be  extremely  im- 
portant.   There  are  several  possibilities:    (a)   Fusion  of  the 
two   kidneys,    "horseshoe  kidney,"  with  one  or  two  ureters. 
(6)  Absence  of  one  kidney  with  an  enlarged,   hypertrophied 
opposite  organ,    (c)   Displacement  of  one  or  both  kidneys,  or  of 

207 


U/i£Tfifi'/i 


Fig.  43. — Diagram  of  urinary  organs. 


208       ESSENTIALS  OF  SURGERY  FOR  NURSES 


K/DNEY 


a  fused  organ,  which  may  be  discovered  as  a  pelvic  mass  and 
mistaken  for  a  tumor. 

Clinical  evidence  is  rarely  suggestive,  and  the  condition  is 
most  often  discovered  at  exploratory  operation  or  autopsy. 
Catheterizing  the  ureters,  and  especially  X-ray  examinations 
after  catheterization  of  the  ureters,  give  suggestive  evidences. 
In  rare  instances  such  an  anomalous  kidney  presents  serious 
pathological  changes  and  is  removed  without  recognition  of  the 

anatomical   condition.      The 

^'^'njBULES  ^^^^^*  ^^  likely  to  be  deficient 
kidney  substance  for  normal 
function,  and  death  from 
ursemia. 

2.  Atrophy  of  a  kidney 
sometimes  follows  sudden 
complete  obstruction  of  the 
ureter,  as  in  accidental  liga- 
tion of  a  ureter  during  an 
extensive  pelvic  operation, 
and  may  occur  with  no  sug- 
gestive symptoms,  being  com- 
pensated by  hypertrophy  of 
the  opposite  kidney.  De- 
struction of  one  kidney  by 
inflammatory  disease  is  usu- 
ally followed  by  compensa- 
tory hypertrophy  of  the  op- 
posite organ.  Serious  lesions 
may  develop  in  such  a  hy- 
pertrophied  kidney  and  the 
diseased  organ  be  removed,  leaving  the  individual  with  no 
functioning  kidney  tissue,  resulting  in  death  within  a  few 
days.  Preceding  any  operation  likely  to  terminate  in  neph- 
rectomy, it  is  necessary  that  exhaustive  studies  be  carried 
out  to  determine  the  presence  and  functional  capacity  of  the 
opposite  kidney. 

3.  Hydronephrosis,  a  dilatation  of  the  pelvis  of  the  kidney,  is 
usually  the  result  of  incomplete  or  intermittent  obstruction  of 
the  ureter,  and  stasis  of  urine.  This  may  be  caused  by:  (a) 
Constriction   of  the  ureter;  (6)  presence   of    a    calculus;  (c) 


/fWNEY 
CORTEX 


COLLECT/NG 
TUBULES 


Fig.  44. — Pelvis  of  kidney,  with  collecting 
tubules,  and  origin  of  ureter. 


THE  URINARY  TRACT :  KIDNEYS  209 

pressure  of  a  tumor,  or  (d)  lesions  of  the  bladder.  There  results 
a  dilatation  of  the  kidney  pelvis,  compression  and  destruction  of 
kidney  tissue,  and  the  formation  of  a  tumor  of  considerable  size. 

Complications  are  infection,  and  formation  of  calculi  or 
concretions.  Indications  for  surgical  treatment:  An  abdomi- 
nal tumor,  pressurensymptoms,  evidence  of  sepsis,  or  calculus 
formation. 

Treatment  includes:  Removal  of  the  obstruction,  plastic 
operation  on  the  ureter,  reconstruction  of  the  kidney  pelvis,  or 
nephrectomy. 

4.  Displacement  of  one  or  both  kidneys  may  occur  during 
adult  life,  with  or  without  symptoms.  Causes :  (a)  Congenital 
weakness  of  abdominal  muscles  and  lack  of  intra-abdominal 
support,  usually  associated  with  ''ptosis,"  or  displacement  of 
the  abdominal  organs,  liver,  stomach  or  colon-  (See  p.  160.) 
(6)  Severe  injury  or  falling,  (c)  Sudden  or  rapid  loss  of  weight 
with  absorption  of  the  surrounding  fatty  capsule  support,  (d) 
Following  pregnancy  or  weakening  of  the  abdominal  muscles. 
Symptoms  are  frequently  absent  and  often  are  not  characteristic : 
local  pain  and  sense  of  weakness,  presence  of  a  m.ovable  tumor, 
pressure  on  other  structures,  possibly  intermittent  hydro- 
nephrosis with  severe  pain.  Many  cases  are  discovered  acci- 
dentally in  the  course  of  an  examination,  and  cause  no  effects 
which  justify  radical  measures. 

Principles  of  Treatment. — (a)  Hygienic  and  constitutional 
measures  to  improve  the  general  health,  strengthen  the  tone  of 
the  abdominal  muscles,  and  stimulate  the  development  of  the 
supporting  structures,  (b)  Special  belts  and  supports  are  used 
with  success  in  many  cases,  (c)  Surgical  operation,  fixation  of 
the  kidney  to  the  posterior  abdominal  wall  is  indicated  and  suc- 
cessful in  selected  cases. 

5.  Wounds  of  the  kidney  occur  from  crushing  injury,  stab 
and  gunshot  wounds.  Serious  hemorrhage  takes  place  which 
may  require  surgical  control:  suture,  ligation  of  vessels,  or 
nephrectomy.  A  hsematoma  may  develop  in  the  perirenal  fat, 
and  require  evacuation.  "Hematuria,"  blood  in  the  urine,  is  a 
constant  finding  in  all  cases  of  serious  injury  to  the  kidney. 

B.  Infection  of  the  kidney:  1.  Acute  processes  are  derived 
from  one  of  two  sources,  secondary  to  foci  of  infection  elsewhere 
in  the  body:  (a)  Metastatic  infections  through  the  blood  stream 
14 


210       ESSENTIALS  OF  SURGERY  FOR  NURSES 

associated  with  a  more  or  less  remote  septic  infection,  tonsillitis, 
for  example,  (h)  Ascending  infection  by  way  of  the  lumen  or 
wall  of  the  m-eter  is  associated  with  infections  of  the  bladder 
and  stasis  of  urine. 

(a)  Metastatic  abscesses  in  the  kidney  substance  are  obscure 
in  development  and  often  present  but  Uttle  characteristic  evi- 
dence. There  are  constitutional  reactions  of  sepsis:  chills,  fever, 
and  leucocytosis.  Locally  there  may  be  pain  and  tenderness, 
and  possible  suggestive  urinary  findings:  albumen,  pus-cells, 
and  red-blood  cells.  In  rare  cases  the  causal  bacteria  are  demon- 


FiG.  45. — Knee-chest  position. 

strated  in  the  urine  or  blood.  Such  an  abscess  may  cause  de- 
struction of  a  kidney  with  comparatively  little  localizing  evi- 
dence. Surgical  exploration  and  treatment  is  indicated  in  cases 
where  a  diagnosis  is  reasonably  definite,  with  drainage  or  ne- 
phrectomy: (i)  to  control  sepsis;  (ii)  to  prevent  further  de- 
struction of  kidney  tissue. 

(b)  Ascending  infections  may  complicate  active  infectious 
processes  in  the  lower  urinary  tract,  or  develop  obscurely  under 
a  variety  of  conditions,  (i)  Stasis  of  urine  in  the  bladder  and 
ureter  due  to  an  obstruction  to  the  outflow,  by  enlarged  pros- 
tate, or  cystocele.  Serious  acute  ascending  infections  are  likely 
to  follow  extensively  cystoscopic  examination  in  some  cases. 


THE  URINARY  TRACT  f  KIDNEYS 


211 


(ii)  Partial  or  intermittent  obstruction  of  a  ureter  with  hydro- 
ureter  and  hydronephrosis,  (iii)  "Cystitis"  and  infections  of 
the  external  meatus  in  children. 

Effects:  Pyelitis  and  inflammation  of  the  pelvis,  dilatation 
of  the  pelvis,  with  infected  urine :  hydronephrosis  (see  p.  208) 
and  pyonephrosis  (pus  in  the  dilated  kidney  pelvis),  with 
destruction  of  kidney  tissue,  and  eventually,  of  the  entire  organ. 

Constitutional  symptoms  are  those  of  a  low  grade,  subacute 
or  intermittent  sepsis,  usually  comparatively  mild,  but  in  cer- 
tain cases  there  is  a  high  grade  of  infection.  Special  evidence  : 
local  pain  and  tenderness,  and  possibly  a  palpable  enlargement 
of  the  kidney.    Urinary  findings  are  characteristic:  pus-cells, 


Fig.  46. — Sims's  position. 


red-blood  cells,  and,  in  some  cases,  the  causal  organisms  can  be 
isolated.  Catheterization  of  the  ureters  may  be  indicated  to 
confirm  the  diagnosis,  to  determine  the  condition  of  each  kidney, 
and  for  special  methods  of  treatment. 

Principles  of  Treatment. — Constitutional  measures  for  sepsis : 
fluids  and  diuretics  to  increase  the  secretion  of  urine  and  flush 
the  kidney  pelvis.  "Urinary  antiseptics":  salol,  hexamethyl- 
ene,  for  their  bactericidal  effect. 

Surgical  measures  are  indicated  in  special  cases :  removal  of 
any  obstruction  to  the  ureter  where  this  is  possible,  in  case  of 
pelvic  tumor  or  hydronephrosis;  incision  and  drainage,  or 
nephrectomy  where  there  is  severe  sepsis,  or  destruction  of  the 
kidney 

2.  Chronic,  tuberculous  infections  of  the  kidney  while  usually 


212       ESSENTIALS  OF  SURGERY  FOR  NURSES 

secondary  to  similar  lesions  in  other  regions  of  the  body,  fre- 
quently occur  in  individuals  who  show  no  clinical  evidence  of 
such  processes,  and  whose  history  gives  no  indication  of  previ- 
ous disease.  Tuberculosis  of  the  urinary  tract  is  primary  in  the 
kidney  and  is  usually  limited  to  one  organ  for  a  considerable 
period  (months  or  years).  It  is  first  evident  clinically  as  a 
bladder  irritation,  characterized  by  painful  and  frequent  mic- 
turition with  an  acid  urine,  being  frequently  mistaken  for  cys- 
titis. Careful  microscopical  examination  of  the  urine  will  usually 
demonstrate:  a  few  pus-cells,  red-blood  cells,  and  tubercle 
bacilli.  In  fairly  advanced  cases  there  may  be  lesions  in  the 
bladder  (ulcers),  but  these  are  secondary  to  the  kidney  infec- 
tion and  frequently  clear  up  if  the  primary  focus  is  removed. 

Signs  and  evidences  of  renal  tuberculosis  include:  (a)  Per- 
sistent bladder  irritation  with  an  acid  urine,  (b)  Urinary  find- 
ings: usually  no  albumen  and  comparatively  few  pus-3ells,  but 
there  are  red-blood  cells,  and  tubercle  bacilli  demonstrated 
in  catheterized  specimens  of  urine,  (c)  Ureteral  catheterization 
is  indicated  in  suggestive  cases:  (i)  to  determine  which  kidney 
is  involved;  (ii)  to  demonstrate  the  functional  capacity  of  the 
opposite  organ,  preceding  nephrectomy,  (d)  When  tubercle 
bacilli  cannot  be  demonstrated  small  amounts  of  urine  are 
injected  into  the  peritoneum  of  guinea  pigs,  followed  by  the 
development  of  characteristic  tubercular  lesions  in  these  animals, 
(e)  Local  pain,  tenderness,  and  possibly  a  palpable  tumor  may 
be  present.  (/)  Constitutional  evidence  of  tuberculosis:  weak- 
ness, loss  of  weight,  fever,  and  night  sweats  are  usually  more  or 
less  evident. 

Principles  of  Treatment. — Early  recognition  is  the  first  es- 
sential. Cases  of  persistent  bladder  symptoms  with  a  clear  acid 
urine,  especially  with  suggestive  constitutional  evidences,  call 
for  an  intensive  study.  Preceding  surgical  treatment,  it  is  nec- 
essary to  have :  (i)  exact  diagnosis  of  the  site  of  the  lesion,  and 
(ii)  knowledge  of  the  functional  capacity  of  the  opposite  kidney. 
When  the  process  is  limited  to  one  kidney,  removal  of  that 
organ  is  indicated,  and  is  usually  followed  by  good  results. 
Constitutional  and  specific,  "tuberculin"  therapy  must  be 
continued  for  months  and  years  to  insure  permanent  cure. 

C.  Urinary  calculi  are  formed  from  calcium,  uric  acid, 
oxalic  salts,  and  other  substances  which  normally  are  held  in 


THE  URINARY  TRACT:  KIDNEYS  213 

solution  in  the  urine.  Under  pathological  conditions,  these 
salts  may  be  deposited  in  the  substance,  or  pelvis  of  the  kidney, 
forming  solid  concretions  or  calculi. 

Predisposing  Causes. — 1.  Remote  constitutional  or  metabolic 
disturbances,  resulting  in  abnormal  amounts  of  various  salts 
in  the  urine,  or  altering  the  composition  of  the  urine  so  that 
these  substances  are  not  held  in  solution. 

2.  Anatomical  changes  in  the  ureter  or  kidney  pelvis,  causing 
stasis  of  urine,  and  infection. 

3.  Infection,  destruction  of  epithelium,  forming  necrotic 
tissue  which  acts  as  a  foreign  body,  serving  as  a  nucleus  for  the 
formation  of  calculi. 

Effects  and  Symptoms. — 1.  Calculi  in  the  substance  of  the 
kidney  or  pelvis  cause:  (a)  Irritation  and  tissue  destruction, 
local  pain  and  tenderness  which  is  persistent  and  tends  to  radiate 
to  the  inguinal  region.  Rontgen-ray  plates  show  the  shadow  of 
most  stones,  and  form  an  important  diagnostic  procedure.  (6) 
Infection  and  pyelitis  is  a  frequent  complication,  (c)  Changes 
in  the  epithelium  of  the  pelvis,  due  to  persistent  irritation,  are 
believed  to  predispose  to  cancer,  (d)  Ureteral  colic  is  caused  by 
fragments  of  a  calculus  passing  into  the  ureter,  where  they  may 
lodge  and  cause  a  permanent  occlusion.  (e)  Calculi  are  often 
retained  in  the  bladder  and  form  a  nucleus  for  the  development 
of  stone  in  that  organ. 

2.  Ureteral  colic,  due  to  the  passage  of  stone  in  the  ureter, 
is  characterized  by  most  intense,  prostrating  pain,  radiating  to 
the  groin,  and  requires  large  doses  of  morphine  to  give  relief. 
There  may  be  temporary  suppression  of  urine  during  the  attack, 
which  is  usually  of  several  hours  duration.  Constitutional 
evidences,  aside  from  prostration,  are  usually  absent  unless 
there  is  infection  of  the  kidney,  or  organic  disease  of  that  organ. 

Principles  of  Treatment. — (a)  Ureteral  colic  calls  for  relief  of 
pain  by  adequate  doses  of  morphine  or  inhalations  of  chloro- 
form and  hot  applications  or  "  stupes  "  locally.  Such  an  attack  is 
often  the  first  indication  of  stone-formation  in  the  kidney,  and 
recurrence  is  likely  at  any  time,  (b)  Surgical  measures  may  be 
indicated  by:  (i)  Evidence  that  the  calculus  has  lodged  in  the 
ureter,  (ii)  Presenceof  other  stones  in  the  kidney  demonstrated 
by  the  X-ray.     (iii)  Evidence  of  stone  in  the  bladder. 

Surgical  measures  include:    (i)  Exposure  of  the  ureter  and 


214       ESSENTIALS  OF  SURGERY  FOR  NURSES 

removal  of  the  stone,  (ii)  Removal  of  calculi  from  the 
kidney  pelvis  with  plastic  operation  to  prevent  further  stasis  of 
urine,  or  drainage  of  the  kidney  for  infection,  (iii)  Nephrec- 
tomy, when  the  kidney  is  extensively  involved,  (iv)  Stones  in 
the  bladder  (see  later). 

D.  Tumors  of  the  Kidney. — Benign  growths,  except  en- 
largements due  to  hypertrophy,  hydronephrosis,  or  inflamma- 
tion, are  comparatively  rare.  Malignant  growths  include  two 
varieties : 

1.  Hypernephroma,  an  abnormal  development  of  atypical 
tissue  resembling  fetal  kidney  or  adrenal  structure.  There  are 
no  localizing  signs  or  symptoms  till  the  growth  reaches  consid- 
erable size,  when  it  can  be  palpated  and  recognized  as  a  kidney 
tumor.  Metastatic  growths  occur  relatively  early  and  may 
present  the  first  evidence  of  malignant  disease,  but  give  a  hope- 
less prognosis.  Surgical  removal  is  indicated  in  case  the  growth 
is  limited  to  the  kidney. 

2.  Cancer  of  the  kidney  usually  develops  in  the  region  of  the 
hilum  or  pelvis.  Special  predisposing  factors  are  irritations 
from  calculus  or  sepsis.  Early  symptoms  and  signs  are:  local 
pain,  blood  in  the  urine,  coming  from  one  kidney,  and  later  a 
palpable  tumor.  "Hsematuria"  is  always  an  important  finding 
and  suggests  the  presence  of  a  serious  lesion,  tuberculosis, 
calculus,  or  cancer,  and  indicates  an  intensive  study  of  the  case. 
Lymphatic  involvement  and  metastases  occur  fairly  late,  and 
early  nephrectomy  offers  a  reasonable  prognosis  for  cure. 

The  Ureters  are  mucous-lined  ducts  extending  from  the 
hilum  of  the  kidney  to  the  base  of  the  bladder.  The  walls  con- 
tain non-striated  muscle  fibres  and  the  ureters  have  an  active 
peristalsis  which  tends  to  carry  solid  substances  to  the  bladder. 
The  ureters  extend  behind  the  peritoneum  into  the  pelvis,  where 
they  lie  in  close  relation  to  certain  blood-vessels,  superior  hem- 
orrhoidal and  uterine  arteries,  and  may  be  injured  or  ligated  in 
controlling  bleeding  from  these  vessels  at  surgical  operations. 
They  pass  obliquely  through  the  wall  of  the  bladder  in  such  a 
manner  as  to  prevent  regurgitation  of  urine.  Calculi  often 
lodge  at  this  point. 

A.  Anatomical  anomalies  are  rare,  usually  being  discov- 
ered by  cystoscopic  examination.  When  present,  they  suggest 
the  possibility  of  anomalous  kidney  structure  or  position. 


THE  URINARY  TRACT :  BLADDER  215 

B.  Injury  to  the  ureter  usually  occurs  during  surgical 
operation,  hysterectomy,  or  resection  of  the  rectum. 

1.  Wounds  may  escape  immediate  notice,  but  are  followed 
by  leakage  of  urine  into  the  pelvis  with  sepsis  and  sloughing 
of  tissue.  Prompt  drainage  gives  temporary  relief,  and  later 
suitable  anastomosis  may  be  made,  or  the  ureter  may  be  im- 
planted into  the  bladder.  In  some  cases  nephrectomy  may  be 
necessary. 

2.  Ligation  of  the  ureter  is  an  occasional  accident  in  connec- 
tion with  tying  the  uterine  artery,  resulting  in  complete  obstruc- 
tion of  urine  from  the  corresponding  kidney.  Provided  the 
opposite  organ  is  functionally  competent,  this  may  be  followed 
by  a  syraptomless  atrophy  of  the  involved  kidney.  In  some 
cases  nephrectomy  may  be  necessary. 

C.  Obstruction  of  the  ureter:  (1)  Complete  occlusion 
results  in  a  temporary  hydronephrosis  and  finally  atrophy  of 
the  kidney.  (2)  Partial  obstruction  or  kinking  of  the  ureter  is 
followed  by  hydronephrosis,  stasis  of  urine,  pyelitis,  sepsis,  or 
calculus  formation.  Causes:  Ligation  or  compression  at  opera- 
tion, occlusion  by  calculus,  constriction  from  ulceration,  pres- 
sure of  tumors. 

Surgical  treatment:  Removal  of  the  cause  when  possible, 
plastic  operation  to  correct  the  deformity,  removal  of  the  kidney 
where  there  is  serious  infection. 

D.  Infections  of  the  ureter  are  usually  secondary  to  those 
of  the  kidney  or  bladder,  (l)  Tuberculosis  of  the  kiditiey  is  fol- 
lowed by  ulceration  of  the  ureter,  sometimes  to  the  extent  of 
occluding  the  lumen,  and  the  tuberculous  process  may  be  isolated 
from  the  lower  urinary  tract.  It  is  frequently  necessary  to 
remove  a  tuberculous  ureter  in  the  surgical  treatment  of  renal 
tuberculosis. 

2.  Infections  of  the  bladder  with  stasis  of  urine  are  followed 
by  an  ascending  infection  either  in  the  wall  or  lumen  of  the 
ureter.  There  is  commonly  a  stasis  of  urine  in  the  ureter, 
"hydro-ureter,"  and  later  a  pyelitis.  Treatment  is  essentially 
that  of  the  pyelitis  and  the  causal  condition. 

The  Bladder. — (A)  Functional  disturbances.  (B)  Surgical 
lesions. 

The  bladder,  located  in  the  true  pelvis  back  of  the  sym- 
phisis pubis,  lies  partly  in  the  loose  fatty  tissue  of  the  pelvis, 


216       ESSENTIALS  OF  SURGERY  FOR  NURSES 

and  the  upper  part,  "fundus,"  is  covered  by  a  reflection  of  the 
peritoneum  so  that  it  projects  into  the  free  peritoneal  cavity. 
The  bladder  is  described  as  a  pear-shaped  organ,  with  the  upper 
part,  "fundus,"  covered  with  peritoneum,  and  a  base  or  "tri- 
gone" which  receives  the  ureteral  openings  at  its  upper  angles, 
and  empties  into  the  "urethra"  at  the  lowest  point, 

A.  Functional  Disturbance.  —  (1)  Incontinence.  (2) 
Retention.  (3)  Residual  urine.  Normal  control  of  the  bladder 
lies  in  the  voluntary  muscle  or  "sphincter"  surrounding  the 
upper  part  of  the  urethra,  and  is  under  voluntary  control  of  the 
nervous  system  through  a  "nerve  centre"  in  the  lumbar  region 
of  the  spinal  cord. 

1.  Incontinence  of  urine  is  characterized  by  constant  drib- 
bling of  urine,  or  involuntary  micturition.  It  may  be  due  to: 
(a)  Paralysis  of  the  sphincter  from  disease  of  the  central  nervous 
system:  tabes,  cerebral  syphilis,  or  injuries  to  the  centre  in  the 
spinal  cord,  fracture  of  the  vertebral  column.  (6)  Mental  defi- 
ciency, or  deficient  thyroid  secretion,  (c)  Injury  to  the  sphincter 
or  urethra  from  surgical  operation  or  difficult  obstetrical  delivery. 
Repair  is  possible  in  most  cases,  (d)  "  Paradoxical  incontinence," 
with  continued  dribbling,  due  to  atony  of  the  bladder  from 
overdistention,  and  retention  of  urine.  This  condition  is 
easily  mistaken  for  a  simple  incontinence  and  the  erroneous 
conclusion  reached  that  the  bladder  is  empty,  when  in  fact  it 
is  tremendously  overdistended.  Catheterization  makes  the 
diagnosis  and  usually  relieves  the  condition,  though  it  may 
have  to  be  repeated. 

2.  Retention  of  urine  may  be  due  to:  (a)  "Anuria,"  lack  of 
secretion  of  urine  from  constitutional  causes,  and  catheteriza- 
tion demonstrates  an  empty  bladder.  (6)  In  the  male  urethra: 
mechanical  obstruction,  "stricture,"  enlarged  prostate.  In 
the  female:  pelvic  tumors,  pregnancy,  especially  during  labor, 
caruncles  or  painful  ulcers  of  the  urethra,  (c)  Temporary  psy- 
chical influences,  ((i)  Post-operative  retention,  due  to:  (i)  Absence 
of  secretion  from  lack  of  fluids;  (ii)  irritation  from  the  opera- 
tion; (iii)  overdistention;  (iv)  inability  to  use  a  bed-pan  or 
urinal  in  bed.  The  effects  of  a  simple  temporary  retention  are 
unimportant  if  promptly  relieved  except  from  infection  and 
cystitis  due  to  careless  or  repeated  catheterization. 

Principles  of  Treatment, — Palliative  measures  include:  hot 


THE  URINARY  TRACT:  BLADDER  217 

stupes  over  the  lower  abdomen,  "pitcher  douches,"  enemas, 
hot  sitz  baths,  and  the  sitting  posture  when  this  is  possible. 
The  catheter  is  to  be  reserved  as  a  last  resort,  since  even  a  single 
catheterization  may  set  up  a  cystitis,  and  frequent  repetition  is 
almost  sure  to.  This  is  especially  true  in  cases  of  obstruction 
where  there  is  residual  urine  in  the  bladder.  In  some  cases 
with  sudden  obstruction  the  passage  of  the  catheter  may  be 
quite  difficult  and  do  serious  damage  to  the  urethra.  This 
occurs  most  often  in  the  male,  and  these  cases  are  usually  cared 
for  temporarily  by  the  surgeon,  followed  by  special  treatment: 
dilatation  of  strictures,  or  operation  to  correct  and  remove 
the  cause.  In  the  female,  except  during  labor,  the  glass  or  metal 
catheter  is  the  simplest  to  sterilize  and  use.  Good  light  and 
exposure  of  the  urethral  opening  is  necessary  to  avoid  contami- 
nating the  sterile  catheter  by  contact  with  the  bedding  or 
clothing. 

3.  Accumulation  of  residual  urine  in  a  pouch  or  sacculation 
of  the  bladder,  which  is  not  drained  in  ordinary  micturition, 
may  occur  in  certain  types  of  obstruction  of  the  urethra,  or 
relaxation  of  the  anterior  vaginal  wall,  "cystocele." 

Results  are:  (a)  Stasis  of  urine;  (6)  cystitis;  (c)  calculus 
formation.  Contamination  of  such  a  bladder  by  a  septic  catheter, 
or  septic  material  carried  up  from  the  lower  urinary  tract,  may 
be  followed  by  an  active  cystitis,  and  severe,  or  fatal,  ascending 
infection  of  the  kidneys. 

Principles  of  Treatment. — ^Whenever  possible  the  cause  must 
be  corrected  by  suitable  surgical  operation.  In  other  cases  it  is 
necessary  to  depend  on  regular  aseptic  catheterization  to  drain 
the  residual  urine. 

B.  Surgical  Lesions. — (1)  Wounds.  (2)  Infections.  (3) 
Calculus.     (4)  Tumors. 

1.  Wounds. — Injuries  to  the  bladder  may  be  caused  by:  (a) 
Penetrating  wounds.  (6)  Crushing  injury,  especially  with  a 
distended  bladder,  (c)  Fracture  of  the  pelvis,  (d)  Difficult 
obstetrical  delivery,  (e)  Accidents  at  surgical  operations  where 
the  bladder  is  not  empty,  or  has  been  displaced  by  pathological 
conditions,  tumors,  pelvic  abscesses,  or  is  present  in  a  hernia. 
Effects:  "Extravasation  of  urine" :  (i)  Into  the  peritoneal  cavity 
with  peritonitis;  (ii)  into  the  surrounding  connective  tissue 
with  cellulitis  and  sepsis. 


218       ESSENTIALS  OF  SURGERY  FOR  NURSES 

The  characteristic  findings  are:  blood  in  the  bladder;  cath- 
eterization a  few  hours  later  demonstrates  that  there  is  no 
urine  in  the  bladder.  Evidences  of  peritonitis  or  sepsis  are  pres- 
ent within  twenty-four  hours.  Treatment  consists  of  prompt 
surgical  measures:  (i)  To  drain  the  infected  tissues;  (ii)  to  repair 
the  wound  in  the  bladder. 

Operations  of  the  bladder:  "Cystoscopy,"  the  introduction 
of  a  special  instrument  through  the  urethra  which  allows  of 
visual  inspection  of  the  bladder  wall  and  contents,  catheteri- 
zation of  the  ureters,  or  certain  operations.  ''Cystotomy"  for 
the  removal  of  stones  or  new-growth  may  be  (i)  ''supra-pubic," 
i.e.,  through  the  abdomen  by  extra-peritoneal  exposure  of  the 
bladder,  (ii)  "perineal"  in  the  male,  or  rarely  (iii)  "vaginal" 
in  the  female.  ' '  Cystostomy ' '  for  temporary  drainage  is  usually 
supra-pubic  with  special  apparatus  or  tubes  for  collecting  the 
urine.  A  special  "retention  catheter"  in  the  urethra  is  used  in 
certain  conditions  after  bladder  operations,  for  the  repair  of 
wounds  of  that  structure. 

2.  Infections  of  the  bladder,  "cystitis":  (a)  Secondary  to 
kidney  tuberculosis  as  already  considered,  is  characterized  by 
an  acid  irritating  urine,  comparatively  clear  of  pus,  but  con- 
taining red-blood  cells  and  tubercle  bacilli.  Cystoscopic  exam- 
ination will  demonstrate  areas  of  ulceration,  usually  about  the 
affected  ureter,  and  will  enable  the  surgeon  to  collect  the  urine 
from  each  kidney  separately.  This  procedure  is  indicated  in  all 
such  persistent  cases. 

Principles  of  Treatment. — Control  of  the  cause,  i.e.,  removal 
of  the  tuberculous  kidney  when  this  is  possible.  In  late  cases 
palliative  measures,  irrigations  and  instillations  into  the  bladder 
are  used. 

(h)  Other  types  of  cystitis  are  usually  subacute  and  tend  to 
become  chronic.  They  are  characterized  by:  frequent  mictu- 
rition accompanied  with  pain,  alkaline  offensive  urine,  often 
with  an  ammoniacal  odor,  and  containing  pus-cells,  bladder 
epithelium,  crystals,  and  bacteria. 

Causes:  (a)  A  partial  obstruction  of  the  urethra.  (6)  Resid- 
ual urine,  (c)  Urethritis  (gonorrheal  infections  often  compli- 
cated by  secondary  infection  with  other  organisms:  B.  coli). 
(d)   Careless  catheterization. 

Results   and   complications:      Irritable   bladder,   lessened 


THE  URINARY  TRACT:  URETHRA  219 

capacity  of  that  structure,  infection  of  residual  urine,  ascending 
infection  of  the  ureter  and  kidney,  and  calculus  formation. 

Principles  of  Treatment. — Medicinal :  fluids  and  diuretics  to 
increase  the  flow  of  urine  and  to  alter  the  reaction.  Urinary 
antiseptics.  Irrigations  and  instillations  in  certain  cases,  or  a 
permanent  catheter.  Surgical  relief  of  urethral  obstruction  and 
drainage  of  residual  urine  is  indicated,  but  in  some  cases  a  pre- 
liminary cystostomy  is  done  for  drainage  till  the  condition  of 
the  patient  improves. 

3.  Calculi  of  the  bladder  resemble  those  of  the  kidney  in 
composition.  Causes:  (a)  Retention  of  kidney  calculi  which  have 
reached  the  bladder.    (6)  Residual  urine  with  cystitis. 

Symptoms :  Pain,  frequent  micturition,  with  severe  pain  and 
bleeding  at  the  completion,  free  blood  in  the  urine.  Symptoms 
are  usually  worse  during  the  day  when  the  patient  is  up  and 
about. 

Effects:  Cystitis,  pyelitis,  increase  in  the  size  of  the  stone. 
Treatment  is  usually  operative,  removal  of  the  stone  by  cystot- 
omy. In  selected  cases,  soft  stones  can  be  crushed  by  special 
instruments  introduced  through  the  urethra. 

4.  New-growths  are  usually  derived  from  the  epithelium  of 
the  bladder,  (a)  Benign  ''papillomas"  are  often  multiple  and 
hang  freely  in  the  bladder.  In  rare  cases  such  tumors  occlude 
the  urethra  and  cause  urinary  obstruction.  There  are  no  char- 
acteristic symptoms  of  such  tumors  aside  from  bladder  irritation 
and  pain.  The  diagnosis  is  usually  made  by  cystoscopic  exami- 
nation or  exploratory  cystotomy.  Removal  of  benign  polyps  or 
papillomas  may  be  accompHshed  by:  (i)  Electro-cautery  or 
snare  through  the  urethra,  or  (ii)  by  cystostomy. 

(6)  Malignant  growth,  cancer,  is  more  often  single,  and  is 
characterized  by  bleeding  and  pain.  Examination  by  cystoscopy 
or  cystostomy  shows  infiltration  about  the  base  of  such  a  tumor 
and  involvement  of  the  bladder  wall.  Treatment:  (i)  Radical 
removal,  with  a  free  margin  of  bladder  wall,  and  plastic  recon- 
struction of  the  bladder,  (ii)  Removal  is  also  successful  by  spe- 
cial forms  of  electrolj^'sis  in  certain  extensive  cases. 

Urethra. — The  female  urethra  is  short  and  easily  access- 
ible to  examination  and  treatment. 

1.  Urethritis,  gonorrheal,  usually  associated  with  lesions  of 
the  genital  tract,  is  of  short  duration  and  accompanied  with  but 


220       ESSENTIALS  OF  SURGERY  FOR  NURSES 

few  complications  of  the  urinary  tract.  There  is  a  tj^pe  of  ascend- 
ing infection  of  the  urethra,  bladder,  and  ureter  to  the  pelvis  of 
the  kidney,  due  to  the  B.  coli  or  staphylococcus,  not  infrequent 
in  children,  especially  girls. 

2.  Injuries  due  to  difficult  obstetrical  operations  are  likely  to 
cause  temporary  retention  of  urine  from  pain  and  irritation  of 
the  urethra.  More  serious  injury  which  involves  the  sphincter 
results  in  permanent  incontinence.  Immediate  repair  relieves 
the  pain  and  retention,  and  plastic  reconstructive  operation  is 
indicated  in  cases  of  incontinence. 

3.  Urethral  ''caruncle"  is  a  small,  highly  sensitive  tumor  of 
the  female  urethra  found  especially  at  the  external  ''meatus." 
The  condition  is  associated  with  painful  micturition  or  slight 
bleeding,  and  is  recognized  by  local  examination. 

Principles  of  Treatment. — Cautery  by  silver  nitrate,  or  act- 
ual cautery  and  surgical  removal. 

4.  Cancer  of  the  urethra  is  comparatively  rare,  but  is  highly 
malignant  and  most  often  inoperable. 

Male  urethra  is  longer  and  more  complicated  in  structure. 
Inflammation,  "urethritis,"  usually  gonorrheal,  is  more  per- 
sistent and  difficult  to  eradicate.  Directly  or  indirectly  the  con- 
dition gives  rise  to  several  serious  surgical  lesions :  peri-urethral 
abscess,  stricture  of  the  urethra,  sudden  retention  of  urine,  and 
deep-seated  perineal  abscess. 

The  prostate  gland  surrounds  the  male  urethra  and  base  of 
the  bladder.  It  is  subject  to  inflammatory  enlargement,  benign 
hjqDertrophy,  or  tumors,  all  of  which  conditions  interfere  me- 
chanically with  complete  normal  evacuation  of  the  bladder. 
There  then  results  accumulation  of  residual  urine  in  the  bladder, 
and  the  associated  complications.  In  certain  cases  showing 
mechanical  disturbance,  the  enlarged  prostate  is  removed  by 
surgical  operation. 

DEMONSTRATIONS 

1.  Demonstration  of  urinary  organs  on  anatomical  chart. 

2.  Pictures  showing  anomaUes  of  kidneys. 

3.  Specimen  or  pictures  showing  hydronephrosis  with  explanation  of  cause. 

4.  X-ray  plate  with  ureters  catheterized  or  injected  wth  silver  salts. 

5.  Case  showing  ptosis  of  kidney,  demonstration  of  binders  or  supports. 

6.  Histories  of  surgical  infections  of  kidney,  with  specimens  or  pictures. 

7.  Histories  of  pyelitis  of  pregnancy  and  in  children. 

8.  Characteristic  history  of  tubercular  kidney  with  bladder  symptoms. 


THE  URINARY  TRACT:  URETHRA  221 

9.  Demonstration  of  methods  of  securing  and  labeling  specimens  from 
ureteral  catheterization,  laboratory  technique  of  staining  for  T.  B. 

10.  Methods  of  testing  for  kidney  efficiency. 

11.  History  of   cases  of  kidney   calculus,   demonstration  of  specimens. 

Urine  showing  typical  crystals. 

12.  X-ray  plate  showing  calculus  in  kidney  or  ureter. 

13.  Case  showing  tumor  of  kidney,  specimen  or  illustrations. 

14.  Demonstration  of  bladder  on  anatomical  chart. 

15.  Case  showing  tumor  from  distended  bladder,  cases  of  urinary  inconti- 

nence with  explanation  of  cause. 

16.  Methods  of  treatment  of  incontinence. 

17.  Treatment  of  retention,  preparation  for  and  technique  of  catheterization. 

18.  Case  of  residual  urine,  explanation  of   cause,  study  or  catheterized 

specimen. 

19.  Cases  or  histories  of  extravasation  of  urine. 

20.  After-care  of  cystostomy,  retention  catheter,  technique  of  bladder 

irrigation. 

21.  Case  histories  of  bladder  timiors,  also  of  stones. 

22.  Case  or  illustration  showing  urethral  caruncle. 


GLOSSARY 


A 

Abdomen.  (See  Anatomy.)  That 
portion  of  the  body  between  the 
thorax  and  pelvis,  limited  above 
by  the  diaphragm  and  below  by 
the  brim  of  the  pelvic  bones. 
Regions:  hypochondriac,  epigas- 
tric, Imnbar,  mnbUical,  iliac 
and  hypogastric.  Divided  by 
transverse  hnes  through  (1)  the 
tenth  ribs,  and  (2)  the  crest  of 
the  Uiac  bones;  and  perpendicular 
lines  through  the  nipple  or  the 
middle  of  the  clavicles.  Walls 
(see  p.  159  and  Anatomy.) 
Abduction.  To  move  a  part  or  hmb 
from  the  mid-hne  or  axis  of  the 
body. 
Abortion.  1.  The  expulsion  of  the 
impregnated  ovum  before  it  is 
viable,  i.e.,  before  the  first  six 
months.  2.  The  premature  ces- 
sation of  a  pathological  or  natural 
process. 
Abscess.   (See  p.   10.)  A  localized 

collection  of  pus. 
Acid.    (See  Chemistry  and  Pharma- 
cology.)   A  sour  substance  which 
turns  blue  htmus  red,  combines 
with  alkalis  to  form  neutral  salts. 
A.  Boric,    or   Boracic,    H3BO3, 
white  crystals,  mildly  anti- 
septic, used  in  saturated,  3% 
solution,     or     ointment     ia 
about    the    same    strength. 
A.  Carbolic,  phenol,   CeHgOH, 
crystals,  fluid  in  95%  used 
as  caustic  (pure  carbohc),  a 
corrosive  poison,   antiseptic, 
and  analgesic,  used  ia  2% 
sol.  as  irrigation. 
A.  Mineral,  iuclude  nitric,  hy- 
drochloric,    and     sulphuric. 
A.   Organic.   (See  Chemistry.) 
Hydrogen    compounds    con- 
taining carbon  and  oxygen. 


Acne.  A  chronic  skin  disease  involv- 
ing the  sebaceous  glands  par- 
ticularly of  the  face  and  back. 

Acquired.  Not  inherited,  oecurring 
after  birth. 

Actinomyces.  (See  p.  37  and 
special  works.)  A  vegetable  par- 
asite of  cattle,  rarely  seen  in  man. 

Acute.  Sharp,  of  relatively  short 
duration  or  extent  as  compared 
to  chronic.  Characterized  by 
rapid  onset  and  increase  to  a  ch- 
max  and  recovery  or  fatal  ter- 
mination. 

Addison's  disease.  (See  Text-book 
on  Medicine.)  A  wasting  disease 
characterized  by  pigmentation 
of  the  skin,  low  blood  pressure. 
Fatal :  due  to  tuberculous  destruc- 
tion of  the  adrenal  bodies. 

Adduction.  A  movement  by  which 
a  part  or  hmb  is  drawn  toward 
the  mid-line. 

Adenoma.  An  epithelial  tumor  re- 
sembling in  microscopic  struct- 
ure that  of  a  secreting  gland. 

Adenoid.  Resembling  a  gland. 
Adenoids,  masses  of  lymph  tissue 
found  in  the  naso-pharynx.  (See 
p.  138.) 

Adhesion.  An  abnormal  union  be- 
tween two  surfaces,  usually  due 
to  inflammatory  destruction  of 
the  superficial  cells,  especiaUy 
of  peritoneum. 

Adolescence.  Youth,  the  period 
between  puberty  and  maturity. 

Adrenal.  (See  Anatomy  and  Phys- 
iology.) An  organ  having  an 
important  internal  secretion  in- 
fluencing body  metaboUsm. 
Located  above  the  kidney. 

Adrenalin,  also  Epinephrin.  (See 
Pharmacology.)  An  extract  of 
the  active  principle  of  the  adrenal 
gland  supphed  in  solution  of  1 
to  1000. 

223 


224 


GLOSSARY 


Aerobic.  Requiring  oxygen.  (See 
p.  2.) 

Afferent.  Carrying  towards  a 
centre  (nerve  centre).  Centrip- 
etal. 

Agar-agar.  A  gelatinous-like  sub- 
stance which  is  fluid  only  at  a  tem- 
perature higher  than  that  of  the 
body.  Used  as  a  culture  medium 
in  bacteriology,  and  ia  the  treat- 
ment for  certain  types  of  con- 
stipation. 

Air-hunger.  A  type  of  breathing 
due  to  an  insufficient  supply  of 
oxygen  reaching  the  tissues. 

Alimentary  tract.  (See  Anatomy 
and  Physiology.)  The  digestive 
organs  extending  from  the  mouth 
to  the  anus. 

Alkali.  (See  Chemistry.)  Turns 
red  Utmus  blue;  combines  with 
acids  to  form  neutral  salts. 

Alveolar  process.  Pertaining  to  the 
jaw-bone  about  the  roots  of  the 
teeth. 

Amenorrhoea.  Cessation  of  the 
menstrual  periods. 

Ambulant  treatment.  That  which 
allows  the  patient  to  be  up  and 
about. 

Amoebic.  A  pathological  process 
caused  by  the  Amoeba  CoU.  (See 
special  worlds.) 

Ampulla.  (See  Anatomy.)  A  dila- 
ted extremity  of  a  canal  or  pas- 
sage. 

Amputation.  Cutting  away  or  com- 
plete removal  by  the  knife,  also 
by  sloughing  or  gangrene. 

Anaerobic.  (See  Bacteriology  _  and 
Micro-organisms,  p.  2.)  Living 
best  in.  the  absence  of  oxygen. 

Analgesia.  Insensibihty  to  or  ab- 
sence of  pain. 

Anaphylaxis.  (See  Bacteriology 
and  Innnunity.)  A  reaction  in 
the  body  caused  by  the  injection 
of  a  foreign  serum  or  proteid. 

Anastomosis.  1.  A  comjtnunication 
between  blood-vessels.  2.  The 
formation  of  an  artificial  opening 
between  two  hollow  cavities  or 


passages. 
Anatomical, 
ture. 


Pertaining  to  struc- 


Anemia.  Deficiency  of  the  blood 
as  a  whole  or  of  one  of  its  elements. 
Characterized  by  a  decrease  in 
the  number  of  red  blood-cells, 
or  of  the  per  cent,  of  haemoglobin, 
or  both.  Local  A.  due  to  ob- 
struction of  the  blood-supply 
to  a  part. 

Anaesthesia,  Lack  of  sensation. 
Surgical  A.  (See  p.  67.)  Induced 
by  drugs  (anaesthetics), 
causes  loss  of  consciousness 
to  external  painful  stimuli, 
and  relaxation  of  the  vol- 
untary muscles. 

Aneurism.  (See  p.  93.)  A  locahzed 
or  circumscribed  dilatation  of  an 
artery. 

Angioma.  A  tumor  formed  of  blood- 
vessels, capillaries. 

Ankle.  The  joint  between  the  leg 
and  the  foot.      *■' 

Anomaly.  A  marked  deviation 
from  the  normal  structme  or 
function. 

Anorexia.  Absence  of  appetite, 
distaste  for  food. 

Anterior.  Situated  in  front  of,  per- 
taining to  the  part  of  an  organ  or 
structure  situated  in  the  ventral 
or  front  part  of  the  body. 

Anthrax.  (See  special  works.)  A 
disease  of  horses  and  sheep,  ex- 
tremely fatal  in  man. 

Antiseptic.  An  agent  which  prevents 
the  growth  of  bacteria. 

Antitoxine.  (See  Bacteriology.)  A 
substance  which  destroys  or 
neutrahzes  particular  toxines, 
usually  the  sermn  of  a  horse  or 
an  animal  which  has  been  immu- 
nized to  the  specific  infection  in 
question.   Diphtheria. 

Antnmi.  (See  Anatomy  and  p. 
131.)  A  cavity  or  space,  usually 
in  bone,  particularly  those  spaces 
communicating  with  the  nasal 
passages. 

Anuria.  A  suppression  of  urine,  due 
to  lack  of  secretion. 

Anus.  (See  Anatomy.)  The  exter- 
nal opening  of  the  lower  bowel, 
from  the  rectum. 

Aperient.  A  mild  laxative  or  ca- 
thartic. 


GLOSSAHY 


225 


Aphasia.  Partial  or  complete  loss  of 
the  power  of  expressing  ideas  by 
means  of  speech  or  writing,  due 
to  lesions  of  the  brain  centres. 

Aponeurosis.  (See  Anatomy.)  A 
fibrous  membranous  e:!ipansion 
of  a  muscle  tendon,  giving  -attach- 
ment over  a  broad  area,  or  form- 
ing a  fibrous  sheath. 

Apoplexy.  Usually  refers  to  the 
condition  resulting  from  spon- 
taneous hemorrhage  into  the 
skuU  or  substance  of  the  brain. 
(See  p.  108.)  Also  refers  to  any 
spontaneous  hemorrhage  into 
the  tissues  of  any  solid  organ. 

Appendicitis.  (See  p.  191.)  An  in- 
flammation involving  the  vermi- 
form appendix. 

Apposition.  The  accitfate  fitting 
together  of  divided  parts. 

Arachnoid  membrane.  (See  Anat- 
omy.) A  dehcate  membrane  cov- 
ering tne  braia  and  spinal  cord, 
located  between  the  dm-a  and 
pia  mater. 

Areola.  The  pigmented  brownish 
area  surrounding  the  nipple  of 
the  breast. 

Argyol.  (See  Pharmacy.)  A  pro- 
prietary preparation  of  silver, 
said  to  be  non-irritating  e\ren  in 
strong  solution,  10%  to  25%. 

Aristol.  A  proprietary  antiseptic 
dusting  powder. 

Arm.  The  upper  extremity  from 
the  shoulder  to  the  wrist,  some- 
times hmited  to  the  elbow.  Fore- 
arm, from  the  elbow  to  the  wrist. 

Arterio-sclerosis.  (See  Medicine.) 
A  pathological  condition  charac- 
terized by  degeneration,  thick- 
ening, and  weakening  of  the  ar- 
teries. 

Arterio-venous.  Involving  both 
artery  and  vein.  Example:  cer- 
tain aneurisms. 

Articulation.  (See  Anatomy  and 
p.  89.)  A  union  of  bony  surfaces 
which  permits  of  motion. 

Ascites.  (Seep.  167.)  An  abnormal 
collection  of  clear  serous  fluid 
in  the  peritoneal  cavity. 

Aseptic.    (See  p.  4.)   Free  from  bac- 
teria or  micro-organisms. 
15 


Asphyxia.  The  suspension  of  vital 
phenomena  resulting  when  the 
lungs  are  deprived  of  oxygen. 

Aspiration.  A  method  of  with- 
drawing fluids  or  gas  from  a  cav- 
ity with  special  apparatus. 

Aspirator.  Consisting  of  a  hoUow 
needle  or  "trocar"  and  a  suction 
apparatus  or  syringe. 

Asthma.  (See  Medicine.)  A  spas- 
modic or  paroxj'smal  affection  of 
the  bronchi  characterized  by  dys- 
pnoea, cough  and  suffocation, 
due  to  local  or  constitutional 
causes. 

Ataxia.  An  incoordination  of  muscu- 
lar activity;  may  be  general  or 
involve  only  special  groups. 
Locomotor   A.       Also    "Tabes 
Dorsahs."      (See  Medicine.) 

Atmospheric  pressure  or  tension. 
(See  Physiology  and  Physics.) 
The  pressure  exerted  by  the  air 
on  the  surface  of  the  body,  nor- 
mally at  the  sea  level  is  15  pounds 
to  the  square  inch. 

Atony.  Loss  of  power,  particularly 
muscular. 

Atrophy.  Diminution  in  size  of  an 
organ  or  tissue,  as  a  result  of 
degeneration  of  the  cells  or  lack 
of  use. 

Atropine.  (See  Pharmacy.)  An  al- 
kaloid, often  used  in  combination 
with  morphine,  h3^odermicaUy 
in  doses  of  gr.  jl-^  to  xi  o'-  Used  by 
ophthalmologists  to  secure  dila- 
tation of  the  pupU. 

At3T)ical.  Irregular;  varying  from 
the  regular  type  of  structure  or 
function. 

Autogenous.  A  condition  produced 
from  within  the  body;  not  de- 
rived from  external  sources.  Au- 
togenous vaccine,  one  produced 
from  cultures  made  from  the 
particular    infectious    process. 

Auto-intoxication.  Poisoning  caused 
by  substances  derived  from  faulty 
body  metaboUsm,  and  not  from 
external  causes. 

Autopsy.  A  post-mortem  examina- 
tion of  the  body  and  its  organs 
after  death. 

Axilla.  (See  Anatomy.)  The  arm-pit. 


226 


GLOSSARY 


Axis-cylinder.  (See  Anatomy  and 
p.  98.)  That  process  of  a  nerve- 
cell  "neurone"  through  which 
nervous  stimuli  are  transmitted, 

B 

Bacillus,  plural  bacilli.  (See  Bac- 
teriology and  p.  1.)  The  rod- 
shaped  bacteria. 

Bacterium,  plural  bacteria.  (See 
Bacteriology  and  p.  1.)  A  form 
of  micro-organisms. 

Barium  sulphate.  Used  with  but- 
termilk or  potato  in  connection 
with  X-ray  and  fluoroscopic  pic- 
ture of  the  gastro-iutestinal  tract. 

Bartholin's  duct.  That  of  the  sub- 
lingual gland.  Barth  gland.  That 
located  in  the  vulva,  often  involv- 
ed  in    gonorrheal    inflanunation. 

Basedow's  disease.  (See  p.  145.) 
Exophthalmic  goiter. 

Basement  membrane.  (See  Anat- 
omy and  p.  5.)  A  definite  mem- 
brane xmderlying  mucous  epithe- 
lium. 

Bedsore.  An  ulceration  or  necro- 
sis, produced  by  trauma  or  con- 
tinued pressure  on  parts  in  which 
there  is  interference  to  the  blood 
or  nerve  supply. 

Belladonna.  (See  Pharmacy .)  Used  in 
lotions  Or  ointments  for  localsooth- 
ing  effects,  also  given  internally. 

BeUy.     Refers  to  the  abdomen. 

Benign.  (See  Tumors,  p.  42.)  Not 
dangerous  to  life. 

Benzene  (CeHe).  (See  Pharmac}'.) 
A  colorless  hydrocarbon  fluid 
used  for  cleansing  the  skin  pre- 
liminary   to    surgical    operation. 

Benzoates.  (See  Pharmacy.)  Salts 
of  benzoic  acid  used  in  medicine 
as  a  urinary  antiseptic. 

Bichloride.  A  salt  containing  two 
chlorine  equivalents;  often  refers 
to  mercury-bichloride,  Corrosive 

SUBLIMATE. 

Bifurcation.  The  division  of  a  struct- 
ure into   two  equal  branches. 

Bile.  (See  Physiology.)  The  secre- 
tion of  the  Uver.  It  contains 
chiefly  1.  B.-pigments,  bihrubin 
and  bihverdin,  derived  from 
broken-down  blood-cells. 


2.  B.-salts,   sodium   glycocho- 

late   and   tam'ocholate.      3. 

"Cholestrin"      and      mucus 

from  the  gall-bladder. 

BUe-ducts.     (See  Anatomy  and  p. 

200.) 
Biliary.     Referring  to  the  bUe  ap- 
paratus and  ducts. 
Birth.      The   dehvery   of   a   child, 
"parturition." 
B.-canal,   the   passage   in   the 
mother   through   which    the 
child  is  dehvered. 
B.-mark,    pigmented    or    vas- 
cular tumors  present  at  birth. 
B. -palsy,    a    paralysis    due    to 
injury  to  the  nervous  system 
from   accidents  in  dehvery. 
Bismuth  meal.   Preparation  of  salts 
of  bismuth  with  milk  or  potato 
used  in    X-ray  and  fluoroscopic 
pictures  of  the   gastro-intestinal 
tract. 

B.  paste,  also  "Beck's  paste," 
bismuth    subnitrate    in  two 
parts    of    vaseline,    or   with 
addition  of  wax  or  paraffin 
to    give    a    higher    melting 
point.     Used  in  chronic  sin- 
uses or  abscess  cavities. 
Bladder.  A  membranous  sac  for  the 
reception    of    fluids.       Example: 
gaU-bladder.    If  not  quahfied,  re- 
fers to  the  urinary  bladder. 
Blastomyces.     (See   special    works 
and  p.  37.)  A  yeast-like  organism 
infecting   the   skin   and   mucous 
membranes. 
Blood.     (See  Physiology.)     B.-clot, 
coagulated  blood. 

B.  cultures.  (See  p.  14.)  Bac- 
teriological cultures  made 
from  blood  aspirated  from 
the  veins  under  aseptic  con- 
ditions. 
B.  infections,  those  in  which 
the  organisms  have  invaded 
the  general  circulation. 
B.  letting  or  bleeding,  the 
withdrawal  of  blood  from  a 
vein  as  a  therapeutic  measure. 
B.  parasite,  a  form  of  micro- 
organism which  attacks  the 
formed  elements  of  the  blood. 
Example:  malaria.  (See 
Medicine.) 


GLOSSARY 


227 


B.  poisoning.  (See  p.  13.)  The 
extension  of  a  local  infection 
characterized  by  the  inva- 
sion of  the  blood-stream  by 
bacteria  and  their  toxines. 
B.  transfusion.  (See  p.  94.) 
The  operation  of  transferring 
blood  from  one  individual, 
the  "donor,"  to  another, 
the  "recipient."  Direct  trans- 
fusion, by  bringing  the  open 
artery  of  the  donor  into 
actual  contact  with  an  open 
vein  of  the  person  receiving 
the  blood,  aUowing  the  blood 
to  flow  directly  from  one  to 
the  other.  Indirect  trans- 
fusion,when  the  blood  is  with- 
drawn from  the  vein  of  the 
donor  with  a  syringe  and 
injected  iato  the  vein  of  the 
recipient. 
Bone,  bone-marrow.    (See  Anatomy 

and  p.  72.) 
Boil.  A  localized  inflammation  in  the 

skin  and  subcutaneous  tissue. 
Bougie.  A  slender  flexible  cyHndri- 
cal  instrument  used  to  explore  or 
dilate  a  narrow  passage  (ure- 
thra or  oesophagus) ;  made  of  rub- 
ber composition  and  can  not  be 
boiled.  I 
Brachial.    Pertaining  to  the  upper 

extremity. 
Bradycardia.    Slowness  of  the  heart 
beat,  usually  under  50  per  minute 
Brain.   (See  Anatomy.)  The  portion 
of    the    central   nervous    system 
contained   within   the   skull;  in- 
cludes: the  cerebrum,  cerebellum, 
pons   varohi,    and    medulla   ob- 
longata, together  with  the  four 
ventricles. 
Breast.  (See  p.  156.)  The  mammary 

gland. 
Broken  compensation.  (See  Med- 
icine.) A  pathological  condition 
occurring  when  the  heart  is  unable 
to  maintain  a  normal  equihbrium 
of  the  circulating  blood,  resulting 
in  a  venous  congestion  of  the 
tissues. 
Bronchitis.  (See  Medicine.)  An 
inflammation  involving  the  mu- 
cous lining  on  the  bronchi. 


Broncho-pneumonia.  A  similar  in- 
flammation which  also  involves 
irregular  portions  of  the  lung. 

Bubo.  Inflammation  and  swelling 
of  a  lymph-node,  particularly 
in  the  groin. 

Bunion.  A  painful  swelling  usually 
involving  the  bursa  of  the  great 
toe. 

Bursa.  (See  Anatomy  and  p.  91.) 
A  membranous  sac,  interposed 
between  muscle  tendons  or  be- 
tween a  hgament  and  a  bony 
surface.  The  sac  contains  a  syn- 
ovial fluid  and  prevents  friction. 

Button,  Mmnphy's.  A  metal  device 
originated  by  Dr.  J.  B.  Murphy 
used  in  making  an  anastomosis 
between  portions  of  the  gastro- 
intestinal tract.  Button  also  re- 
fers to  the  circular  bit  of  bone 
removed  from  the  skuU  by  a 
trephine. 


Calcification.       The   deposition   of 
calcium  salts  in  certain  tissues. 
Calcium.        (See    Chemistry    and 
Physiology.)    Lime-salts,    impor- 
tant in  the  structure  of  bone  and 
in  certain  concretions. 
Calculus,  plural  calculi.    Stone-hke 
formations    found   in  the    body, 
particularly   in    certain    cavities. 
Biliary   C.    (see   p.  203),  com- 
posed of  bile-salts,  and  found 
in  the  bile-passages. 
Fecal  C,  formed  of   hardened 
material  lodged  in  the  intes- 
tinal tract,  particularly  the 
appendix. 
Urinary  C.  (see  p.  212),  those 
formed  in  the  urinary  tract. 
Callus.    (See  p.  88.)   The  new  bone 
formation  about  a  fracture.  Also  a 
"corn"  or  a  local  area  of  hard 
skin  composed  of  modified  epi- 
thehum. 
Camphor.     (See  Pharmacy.) 

Camphorated  oU,  used  in  ster- 
ile   solution    hypodermically 
as  a  stimulant;  dose  5-15  min. 
Canal.       Any   tubular   passage   or 
channel.      Example:  alimentary, 
femoral,  inguinal. 


228 


GLOSSARY 


Cancellous.  Structure  resembling 
lattice  work,  especially  bony. 

Cancer.  (See  p.  46.)  A  malignant 
tumor  of  epithelial  origin. 

Cancnim  oris.  Ulceration,  often 
gangrenous,  of  the  mucous  mem- 
brane of  the  mouth. 

Canker.  (See  Medicine.)  A  vesicular 
ulceration  of  the  mouth. 

Capillary.  (See  Anatomy  and  p.  54.) 
Tubes  of  minute  size,  hair-Hke. 

Capsule.  A  sheath,  usually  com- 
posed of  fibrous  tissue,  siuround- 
ing  certain  organs  or  benign 
new-growths. 

Caput.  The  head,  also  the  chief 
part  of  an  organ. 

C.  succedaneum.  A  sweUing 
in  or  under  the  fetal  scalp, 
composed  of  blood  or  serum, 
and  due  to  pressure  diuing 
dehvery. 

Carbol-fuschsin,  A  stain  used  ia 
the  identification  of  bacteria, 
particularly  of  the  B.  Tubercle. 

Carbolic  acid,  phenol.     (See  Acid.) 

Carbuncle.  (See  p.  117.)  A  deep- 
seated  circumscribed  suppura- 
tive inflammation  of  the  subcu- 
taneous tissue;  differs  from  a 
boU  in  that  it  involves  several 
points,  forms  less  fluid  pus,  and 
is  more  persistent. 

Carcinoma.  "Cancer."  MaHgnant 
tumor  of   epithelial   origin. 

Cardiac.  Pertaining  to  the  heart, 
"cardia."  Also  that  portion  of 
the  stomfech   nearest  the  heart. 

Caries.  Necrosis  or  death  of  bone 
or  teeth. 

Carotid.  "Artery."  (See  Anatomy.) 
The  principal  artery  of  the  neck, 
supplying  the  brain,  face,  and 
head. 

Carpal.      Pertaining  to  the  wrist. 

Carron  oil.  Composed  of  equal 
parts  of  Unseed  oil  and  lime- 
water,  used  as  first  dressing  for 
burns. 

Caruncle.  Any  small  fleshy  growth, 
often  about  the  urethra  (see  p. 
220)  and  vagina. 

Catamenia.   The  menstrual  periods. 

Catarrh.  Inflammation  of  a  mu- 
cous    membrane,     characterizecl 


by  a  profuse  discharge,  and  no 
artificial  membrane  formation  or 
tissue  necrosis. 

Cathartic.  (See  Pharmacy.)  Adrug 
used  to  produce  evacuations  of 
the  bowels. 

Catheter.  A  hollow  tube  to  be  in- 
serted into  a  cavity  through  a 
normal  opening,  i.e.,  into  the 
bladder  through  the  urethra, 
also  the  eustachian  tubes. 

Caustic.  Irritating,  burning,  capable 
of  destrojdng  tissue. 

Cautery.  A  metal  instnmaent  heat- 
ed by  electric  current  or  actual 
flame,  used  to  destroy  tissue. 

Cecum.  (See  Anatomy  and  p.  192 
and  Fig.  41.)  The  lower  end  of 
the  ascending  colon. 

Celiac.  Pertaining  to  the  abdomi- 
nal cavity,  the   "celom." 

Celiotomy.  A  surgical  operation, 
where  the  abdominal  cavity  is 
opened. 

Cell.  (See  Anatomy.)  The  imit  of 
structure. 

Cellulitis.  (See  p.  19.)  A  diffuse  in- 
flammation involving  loose  tissue. 

Centre.  UsuaUy  N.  centre.  (See 
Anatomy  and  Physiology.)  A 
group  of  nerve-cells  in  the  brain 
or  spinal  cord  which  control  spe- 
cial muscles  or  functions. 

Cephalic.     Pertaining  to  the  head. 

Cerebellum.  (See  Anatomy.)  That 
portion  of  the  brain  located  be- 
low the  cerebrum,  behind  the 
pons  varolii,  and  meduUa  ob- 
longata. 

Cerebnun.  (See  Anatomy.)  The 
principal   portion   of   the   brain. 

Cerebro-spinal.  (See  Anatomy  and 
p.  98.)  Pertaining  to  the  brain 
and  spinal  cord. 

C.  canal.  (See  Anatomy  and 
p.  103,  Fig.  25.)  The  space 
extending  from  the  ventricles 
of  the  brain  through  the 
length  of  the  spinal  cord. 
C.  fluid.  (See  Physiology  and  p. 
103.)  The  serous  fluid  con- 
tained in  the  cerebro-spinal 
canal. 

Cerumen.  The  waxy  secretion  form- 
ed in  the  external  auditory  canal, 


GLOSSARY 


229 


Cervical.  Pertaining  to  the  neck 
(cervix),  or  to  the  structural 
neck  of  an  organ.  Example:  the 
neck,  cervix  of  the  uterus. 

Chancre.  The  primary  syphihtic 
lesion  or  portal  of  entry. 

Changeof  life.  "Menopause."  The 
normal  cessation  of  the  menstrual 
periods. 

Chill.  A  condition  characterized  by 
sensations  of  cold  and  shivering, 
often  the  initial  symptom  of  an 
acute  infectious  process  and  fol- 
lowed by  a  rapid  rise  in  temper- 
ature. 

Chloral  hydrate.  (See  Pharma- 
cology.) A  hypnotic  drug;  dose 
gr.  v-xx. 

Chloroform.  (See  Pharmacology 
and  p.  68.)  A  general  anaes- 
thetic. 

Cholecystitis.  (Seep. 202.)  Inflam- 
mation of  the  gaU-bladder. 

Cholecystectomy.  (See  p.  203.) 
The  surgical  removal  of  the  gall- 
bladder. 

Cholecystostomy.  (See  p.  202.)  The 
drainage  of  the  gaU-bladder 
through  a  surgical  incision  of  that 
organ. 

Cholecystotomy.  (See  p.  204.) 
Exploration  of  the  gall-bladder 
with  immediate  closure. 

CholeUthiasis.  (See  p.  203.)  The 
presence  of  calcuh  in  the  bile 
tract. 

Cholestrin.  (See  Physiology.)  One 
of  the  constituents  of  the  bile, 
usually  held  in  solution,  but  im- 
portant pathologically  in  the  for- 
mation of  gaU-stones. 

Chondroma.  (See  p.  47.)  A  tmnor 
containing  cartilage. 

Chronic.  Of  long  duration;  op- 
posed to  acute  conditions. 

Cicatrix.  The  scar  formed  in  a 
wound,  the  newly  developed 
connective  tissue  which  fills  in 
a  loss  of  tissue  from  injury  or 
infection. 

Ciliated.  (See  Anatomy.)  A  type  of 
epithehum. 

Circulation.  Passing  in  a  circle,  e.g., 
blood.     (See  Physiology.) 


Colateral  C.  (see  p.  26),  that 
which  takes  place  through 
branches  and  anastomoses 
when  the  chief  vessel  is  oc- 
cluded. 
Portal  C,  that  from  the  di- 
gestive tract  and  spleen 
which  is  collected  by  the 
portal  veins  and  passes 
through  the  hver  capillaries, 
to  be  carried  off  by  the 
hepatic  veins  to  the  vena- 
cava. 
Pulmonary  C,  that  from  the 
right  ventricle,  through  the 
lungs,  and  back  to  the  left 
auricle. 
Systemic  C,  the  general  cir- 
culation through  the  arte- 
ries, capillaries,  and  veins, 
as  opposed  to  the  portal 
and  pulmonic. 
Circimiscribed.      Limited,   distinct 

from  surroimding  structures. 
Cirrhosis.  (See  Medicine.)  A  chron- 
ic inflammatory  process  of  an 
organ,  characterized  by  over- 
growth and  infiltration  of  con- 
nective tissue,  most  often  involv- 
ing the  hver. 
Clavicle.        (See    Anatomy.)    The 

collar  bone. 
Cleft-palate.     (See  p.  135.)     A  con- 
genital fissure  of  the  palate. 
Climacteric.    The  period  associated 
■with  the  cessation  of  the  men- 
strual periods;  the  menopause. 
CUnic.    At  the  bedside;  an  institu- 
tion for  the  study  and  diagnosis 
of  medical  conditions. 
CUnical  diagnosis.    That  made  as  a 
result  of  examination  of  the  pa- 
tient and  laboratory  tests,  before 
operation. 
Clonic.    Relating  to  spasmodic  and 
convulsive     muscular      contrac- 
tions, -nith  alternating  periods  of 
relaxation. 
Clot,    "coagulation."      (See  Physi- 
ology.) A  solidification  of  blood 
after  it  has  been  shed. 
Coaptation.    The  accurate  union  or 
adjustment    of    the    edges    of    a 
wound  or  fracture. 


230 


GLOSSARY 


Cocaine.  (See  Pharmacy.)  An  al- 
kaloid anaesthetic,  used  most 
often  as  the  cocaine  hydrochlo- 
rate,  ia  solutions  of  from  1  to  5% 
as  appUcations,  or  1  to  500  hy- 
podermicaUy. 
Colic.  1.  Pertaining  to  the  "colon" 
or  large  intestine.  2.  A  sharp  pain 
in  the  abdomen  supposed  to  be 
due  to  the  spasmodic  contrac- 
tion of  one  of  the  hoUow  canals, 
bUe-passages,  intestiiial  tract,  etc. 
Collapse.  Sudden  severe  depression 
of  the  circulation  associated  with 
hemorrhage,  shock,  or  the  rapid 
loss  of  large  amounts  of  body 
fluid. 
Colles.  A  celebrated  British  sur- 
geon. 

C.'s  fracture.    (See  p.  86.)  That 
of    the    lower    end    of    the 
radius. 
Colon.    (See  Anatomy  and  p.  186.) 

The  large  intestine. 
Colony.      (See    Bacteriology.)       A 
gro-^iih    of    bacteria    in    culture 
media. 
Colostomy.    (See  p.  187.)   The  sur- 
gical formation  of  a  permanent 
opening  in  the  large  intestine  to 
serve  as  an  artificial  anus. 
Coma.    A  state  of  unconsciousness 
from  which  the  patient  can  not 
be  aroused. 
Comminuted.      (See   Fractures,   p. 
78.)    Broken   into   a   nmnber   of 
pieces. 
Compensatory.       Making    good    a 
deficient     function     in     another 
part. 
Complication.     A  condition  arising 
during  the   course   of   a   disease 
and  more  or  less  dependent  on 
it. 
Compound    complicated    fractures. 
(See  p.  78.)    Open  to  the  surface. 
Conception.       FertUization    of    the 
female     germ-cell,     ovum,    inci- 
dental to  pregnancy. 
Concussion.  (See  p.  106.)  A  patho- 
logical condition  resulting  from  a 
blow,  especially  to  the  head. 
Confinement.     Childbirth. 
Congenital.     A  condition  or  defor- 
mity existing  at  birth. 


Congestion.  An  abnormal  accumu- 
lation of  blood  in  a  tissue  or  organ. 

1.  Active  C,  due  to  an  increase 
in  the  arterial  supply. 

2.  Passive  C,  due  to  an  ob- 
struction to  the  venous  re- 
turn from  the  part. 

Conjunctiva.  (See  Anatomy  and 
p.  124.)  The  mucous  membrane 
covering  the  eyeball,  and  Uning 
the  eyehds. 

Consciousness.  The  state  of  being 
aware  of  one's  own  existence  and 
mental  impressions,  also  of  the 
various  sensory  stimuli. 

Constipation.  Any  condition  where 
the  bowels  are  evacuated  irreg- 
ularly, incompletely,  or  at  ab- 
normally long  intervals. 

Constitutional.  A  condition  involv- 
ing the  entire  body  or  organ- 
ism. 

Contagious.  A  condition  or  disease 
wliich  may  be  carried  or  trans- 
mitted from  one  individual  to 
another. 

Contaminate.  To  soil  with  bacteria 
or  material  which  is  not  sterile. 

Contractmre.  A  permanent  short- 
ening or  contraction  of  a  muscle, 
resulting  in  deformity  or  loss  of 
function. 

Contusion.  A  bruise  or  injury, 
usually  without  break  of  the  sur- 
face. 

Convulsion.  (See  Medicine.)  An 
involuntary  spasmodic  contrac- 
tion of  muscles,  either  general  or 
involving  only  special  regions. 
May  be  (1)  clonic,  i.e.,  alterna- 
ting mth  periods  of  relaxation, 
or  (2)  tonic,  without  such  periods. 

Corium.  (See  Histology  and  p.  6.) 
The  tissue  layer  underlying  the 
skin. 

Cornea.  (See  Anatomy.)  The  an- 
terior transparent  part  of  the 
eyeball. 

Corrosive  sublimate.  (See  Phar- 
macology.) The  poisonous  Bi- 
chloride of  Mercury  used  in  so- 
lutions of  from  1-1000  to  1  to 
10,000. 

Cortex.  The  surface  layer,  cere- 
brum, kidney,  etc. 


GLOSSARY 


231 


Cover-glass.  A  thin  piece  of  glass 
used  to  cover  microscopical  prep- 
arations. 
Cradle.  In  surgery,  a  wire  or  wooden 
framework  to  keep  the  weight  of 
the  bed-coverings  from  an  in- 
jured part  of  the  body. 
Cramp.  A  painful  tonic  contraction 

of  a  muscle. 
Cranium.      The  skuU.     "Cranial," 
pertaining  to  the  skuU. 

Craniotomy.  The  surgical  open- 
ing  of   the  skuU.      (See   p. 
108.) 
Cretinism,    (See  p.  143.) ;  A  congeni- 
tal condition   due   to   absent  or 
deficient  thyroid  secretion. 
Crepitus.    (See  p.  79.)    A  sign  pro- 
duced by  the  friction  of  irreg- 
ular bony   surfaces   in   fracture, 
which  can  be  felt  and  heard. 
Crisis.      A  definite  turning  point, 
particularly    in    an    acute  infec- 
tion. 
Croup.   A  pecuHar  cough,  produced 
by  obstruction  of  the  larynx. 
Membranous   C.      Due  to   fi- 
brinous   inflammatory    exu- 
date in  the  larynx  usually 
caused     by     diphtheric     in- 
fection. 
Cultures.      Growth  of  bacteria  in 
artificial  media  for  special  study. 
Cupping.      A   method   of   drawing 
blood  to  the  surface  and  reheving 
congestion  of  deeper  tissues,  by 
the  apphcation  of  heated  cups. 
Cutaneous.    Pertaining  to  the  skin, 

or  "cutis." 
Cyanosis.  A  bluish  discoloration  of 
the  skin,  due  to  congestion  with 
venous  blood,  or  to  a  deficient 
oxygen  content  of  the  blood  from 
local  or  general  conditions. 
Cyst.  Any  cavity  containing  fluid, 
surrounded  by  a  definite  limiting 
membrane  or  capsule.  Also  refers 
to  the  urinary  bladder. 

Cystic.  Pertaining  to  a  cj^st, 
also  to  the  urinary  or  gall- 
bladder. 
Cystitis.  Inflammation  of  the 
urinary  bladder.  (See  p. 
218.) 


Cystoscope.  An  instrument  intro- 
duced into  the  bladder,  through 
the  urethra,  by  means  of  which 
the  mucous  hning  may  be  seen 
and  studied. 

Cystoscopy.  (See  p.  218.)  The  ex- 
amination of  the  bladder  by  means 
of  a  cystoscope. 

D 

Decompression  operation.  (See 
p.  112.)  That  of  relieving  increased 
intracranial  pressure  by  elevating 
depressed  fragments  of  bone,  or 
by  removing  a  portion  of  the 
skull. 

Decubitus.  The  position  of  the 
body  of  the  patient.  Also  refers 
to  a  type  of  bedsore. 

Defecation.  The  evacuation  of  the 
bowels. 

Deformity.  An  abnormality  of 
structure,  congenital  or  acquired. 

Degeneration.         A      pathological 
change  in  the  elements  of  a  sub- 
stance or  tissue,  usually  the  break- 
ing down  from  a  complex  to  a 
simpler  form. 
Malignant  D.     (See  p.  42.)    A 
change  in  the  cell-structure 
of  a  new-growth  by  which 
it    invades    tissue    and    be- 
comes malignant. 

Delirium.  A  condition  of  extreme 
mental  excitement  and  inco- 
ordination. 

Dental.  Pertaining  to  the  teeth, 
"dens." 

Dermal.  Pertaining  to  the  skin, 
"dermis." 

Dermoid.  Resembling  the  skin, 
derived  from  the  skin.  A  special 
type  of  tumor  containing  various 
tissues  derived  from  the  skin. 

Diabetes.  (See  Medicine.)  A  con- 
stitutional disease  characterized 
by  the  presence  of  grape-sugar 
in  the  urine,  and  marked  depres- 
sion. 

Diaphragm.  (See  Anatomy.)  Any 
musculo-membranous  partition, 
particularly  that  between  the 
thoracic   and   abdominal   cavity. 

Diaphysis.  (See  p.  71.)  The  shaft 
of  a  long  bone, 


232 


GLOSSARY 


Diarrhoea.  Any  condition  charac- 
terized by  frequent  and  fluid 
bowel  movements. 

Digestion.  The  process  by  which 
the  food  is  prepared  so  that  it 
can  be  absorbed  and  assimilated 
in  the  body. 

Diphtheria.  (See  Bacteriology  and 
Pediatrics.)  A  type  of  infection 
characterized  by  toxaemia  and 
local  "membrane  formation." 

Diplococcus.  (See  Bacteriology.) 
A  type  of  micrococcus,  which 
occurs  in  pairs.  Example:  pneu- 
mococcus,  gonococcus,  etc. 

Dirty.  Surgically,  anything  which 
is  not  sterile. 

Discharge.  A  pathological  sub- 
stance escaping  from  one  of  the 
body  cavities  or  an  infected 
surface. 

Discrete.  Separate,  distinct  from 
surrounding  tissues. 

Dislocation.  Displacement  of  a 
part,  organ  or  bone  from  its  nor- 
mal position. 

Dixiresis.  An  increase  in  the  amount 
of  urine  secreted. 

Diverticulum.  A  cavity  or  sac 
growing  out  of  and  communica- 
ting with  a  hollow  organ  or  cavity; 
may  be  congenital  or  acquired. 

Dorsum.  The  back,  or  that  part  of 
any  structure  corresponding  to 
the  back. 

Dorsal.  Pertaining  to  the  back. 

Douche.  A  stream  of  water  directed 
against  a  surface  of  the  body  or 
into  one  of  its  cavities;  may  be 
cleansing,  thermal  (for  heat  effect) 
or  antiseptic  and  medicinal. 

Drain.  Any  material  used  to  se- 
cure the  removal  of  discharge 
from  a  wound  or  infected  abscess 
cavity:  glass,  rubber,  gauze  or 
gutta-percha. 

Dressings.  Any  material  used  to 
cover  and  protect  a  woimd. 

Duct.  A  channel  through  which  the 
secretion  of  a  gland  is  carried. 

Dulness.  Lack  of  resonance  on  per- 
cussion. 

Duodeniun.  (See  Anatomy,  also  p. 
184.)  The  upper  twelve  inches  of 
the  small  intestine. 


Dura.  (See  Anatomy,  also  p.  101.) 
The  outer  covering  of  the  brain 
and  cord. 

Dyspnoea.  Difficult  or  labored 
breathing. 

Dysuria.  Painful  urination. 

Dysmenorrhoea  Painful  menstru- 
ation. 

E 

Ecchymosis.  The  extravasation  or 
escape  of  blood  into  the  subcu- 
taneous tissues,  giving  a  bluish- 
black  and  later  yeUow  discol- 
oration. 

Ectoderm.  (See  Anatomy.)  The 
outer  of  the  primary  germ-layers. 

Ectopic.  In  an  abnormal  position, 
e.g.,  E.  gestation,  one  outside  of 
the  uterus. 

Eczema.  (See  Dermatology.)  A 
skin-disease,  chronic  and  non- 
contagious. 

Edema.  An  infiltration  of  the  tis- 
sues with  fluid  or  serum. 

Efferent.  Carrying  away  from  a 
centre,  as  opposed  to  afferent 
nerves,  etc. 

Effusion.  A  pouring  out,  or  ac- 
cumulation of  clear  fluid  or  serum 
into  a  cavity  of  the  body,  usually 
one  of  the  serous  cavities,  pleura, 
etc. 

Elective  operation.  One  where  the 
exact  time  is  a  matter  of  choice, 
as  opposed  to  an  etnergency  ope- 
ration, which  is  urgently  de- 
manded. 

Electrolysis.  The  dissolution  of  a 
chemical  compound  or  a  tissue 
by  passing  an  electric  current 
through  it. 

Emaciation.     Marked  loss  of  flesh. 

Embolus.  (See  p.  95.)  A  portion 
of  tissue  or  bloodclot  carried  in 
the  blood-stream  and  blocking  a 
smaller  vessel  by  occluding  its 
lumen. 

Embryo.  The  product  of  conception 
especially  during  the  first  four 
months  of  intra-uterine  life. 

Emesis.    Vomiting. 

Empyema.  A  collection  of  pus  or 
purulent  fluid  in  a  cavity.  Ex- 
ample: pleural. 


GLOSSARY 


233 


Encapsulated.  Surrounded  by  a 
capsule. 

Encysted.  Enclosed  in  a  definite 
wall  or  layer  of  connective  tissue. 

Endo.    Within. 

Endocardium.  Lining  the  heart. 
Endodenn.     The  primary  em- 
bryonic layer  hning  the  gas- 
tro-intestinal   tract,   etc. 

Enema.  An  injection  given  into  the 
rectum. 

Entero.  Referring  to  the  intestinal 
tract. 
Enterostomy.        An    artificial 
opening,     etc.,     particularly 
into  the  small  intestine. 

Enucleate.  To  sheU  out  of  a  cap- 
sule, referring  to  tumors. 

Enuresis.  An  involuntary  emptying 
of  the  bladder. 

Epigastrium.  The  region  of  the  ab- 
domen corresponding  to  the  po- 
sition of  the  stomach. 

Epilepsy.  (See  Medicine.)  A  ner- 
vous condition  characterized  by 
repeated  attacks  of  loss  of  con- 
sciousness and  convulsive  con- 
tractions of  the  muscles,  more  or 
less  general  in  extent.  Jacksonian 
E.  (see  p.  106.),  convulsive  at- 
tacks involving  special  regions  or 
groups  of  muscles  without  loss  of 
consciousness. 

Epiphysis.  (Seep.  71.)  A  part  of  de- 
veloping bone  separated  from  the 
main  structure  by  a  layer  of 
Epiphysial  cartilage  or  line,  which 
is  later  replaced  by  bone. 

Epistaxis.  (See  p.  132.)  Spontaneous 
hemorrhage  from  the  nose. 

Epithelium.  (See  Anatomy.)  Thespe- 
ciahzed  tissue-cells  which  cover  the 
various  body  surfaces,  and  line  the 
cavities  which  open  on  thesiu:face. 

Epulis.  A  tumor  arising  in  the  alve- 
olar process  of  the  jaw. 

Erosion.  A  destruction  or  necrosis 
of  superficial  tissues. 

Eructation.  Belching,  or  bringing 
up  gas  or  fluid  contents  from  the 
stomach. 

Erysipelas.  (See  Medicine  and  p. 
32.)  An  acute  infection  of  the 
sldn  and  subcutaneous  tissue,  due 
to  some  variety  of  streptococci. 


Ether,  (C2Hg)20.  (See  Pharmacol- 
ogy and  p.  68.)  Used  hypoder- 
micaUy  as  a  stimulant;  dose:  5 
to  10  min.  Also  general  anses- 
thetic. 

Ethyl  chloride,  C2H6CL.  A  gas  kept 
in  metal  containers  imder  pres- 
sure, used  as  a  local  or  general 
anaesthetic . 

Eustachian  tube.  (See  Anatomy 
and  p.  121.)  A  communication  be- 
tween the  naso-pharynx  and 
middle  ear. 

Excision.  The  sm-gical  cutting 
away  or  removal  of  a  part. 

Excreta.  The  normal  discharges 
from  the  body,  particularly, 
feces  and  urine. 

Exophthalmic.  An  abnormal  pro- 
trusion of  the  eyeballs.  (See 
goiter,  p.  145.) 

Exostosis.  A  bony  outgrowth 
from  the  surface  of  a  bone. 

Expectant.  Treatment,  watching 
the  progress  of  a  condition  and 
interfering  only  in  case  of  emer- 
gency, or  for  special  indications. 

Exploratory  operation.  One  which 
is  done  primarily  to  discover 
the  cause  of  symptoms. 

Extension.  Straightening  out  a 
joint  or  flexed  Umb.  In  fractures, 
is  the  force  applied  to  overcome 
deformity  and  shortening. 

Extra.    Without. 

Extradural.     Outside  the  dura 
mater. 

Extravasation.  The  passing  of  a 
fluid,  urine,  outside  its  normal 
cavity  or  duct,  as  a  result  of  rup- 
ture or  injury. 

Exudation.  The  passing  of  fluid, 
serum  or  purulent  material 
through  the  wall  of  a  cavity,  or 
into  a  serous  space;  pleura,  etc. 


Facet.  A  small  flat  surface  of  a  bone, 

usually  muscular  attachment. 
Facial.     Pertaining    to    the    face 

blood  or  nerve  supply. 
Facies.     Expression,   often  typical 

in  certain  conditions:  peritonitis, 

etc. 


234 


GLOSSARY 


Fallopian.    Named  from  Fallopius, 

a  famous  anatomist. 

F.  tubes.  (SeeiVnatomy.)  The 
oviducts. 

Farcy.  (See  special  works.)  Glan- 
ders. 

Fascia.  A  sheath  or  band  of  connec- 
tive tissue;  the  term  is  also  ap- 
phed  to  loose  connective  tissue 
between  muscles. 

Febrile.  Pertaining  to  fever,  or 
increased  body  temperature. 

Feces.  The  contents  of  the  lower 
bowel,  composed  of  undigested 
remains  of  the  food  and  the  ex- 
cretions of  the  intestinal  canal. 

Felon,  also  "Paronychia."  An  ab- 
scess involving  the  terminal  pha- 
lanx of  the  finger,  usually  a  per- 
iostitis, but  may  be  subcutaneous. 

Femoral.  Pertaining  to  the  thigh, 
or  femur.  (See  Anatomy:  fe- 
moral vein,  etc.) 

Fetus.  The  product  of  conception 
during  the  latter  five  months  of 
intra-uterine  life. 

Fetal.    Pertaining  to  the  fetus. 

Fever.  (See  Physiology.)  An  ab- 
normally high  body  temperature. 

Fibroid.  (See  p.  47.)  A  fibrous  tu- 
mor. 

Fibroma.  One  which  is  largely 
composed  of  fibrous  tissue 
or  resembles  it  in  structure. 

First  aid.  The  treatment  given  in 
emergency. 

First  intention.  (See  p.  50.)  Aseptic 
wound  healing. 

Fissure.  A  cleft  or  groove.  Also  a 
crack  or  break  in  the  mucous 
membrane  lining  any  orifice  of 
the  body. 

Fistula.  (See  p.  20.)  An  abnormal 
opening  from  a  hollow  organ  to 
the  surface  of  the  body,  or  be- 
tween two  hollow  organs. 

Flap.  A  mass  of  tissue  partly  sep- 
arated from  its  attachment  or 
blood-supply. 

Flatus.  Gas  or  air  contained  in  the 
intestinal  tract. 

Flexion.  The  bending  of  a  limb  or 
joint,  the  condition  of  being  bent. 

Floating.  Freely  movable;  detached 
from  its  normal  attachment. 


Fluctuation.  A  wave-like  motion 
transmitted  by  fluid  in  a  cavity. 

Fluoroscope.  An  apparatus  for 
viewing  deep  structures;  the  Ront- 
gen  or  "X-rays." 

Focus.  The  site  of  a  morbid  or  in- 
fectious process. 

Follicle.  A  small  secreting  glandu- 
lar mass  or  sac. 

Fomentation.  (See  special  works.) 
A  warm  moist  dressing. 

Fontanelle.  (See  Anatomy.)  The 
spaces  between  the  bones  of  the 
skull  in  infancy,  before  fusion  or 
ossification  is  complete. 

Foramen.  A  hole  or  perforation, 
particularly  in  bone  or  limiting 
membrane. 

Forceps.  An  instrument  composed 
of  two  blades  and  interlocking 
handles,  used  to  grasp,  compress, 
or  pull  an  object. 

Dental  F.    For  extracting  the 

teeth. 
Hemostatic  F.     For  compress- 
ing   blood-vessels    and    con- 
trolling  hemorrhage. 
Tissue    or    dissecting   F.    For 
grasping  tissue  in  operating. 
Obstetrical  F.    Used  in  obstet- 
rics to  apply  to  the  fetal  head 
and  to  assist  at  delivery. 

Formaldehyde.  (See  Pharmacolo- 
gy.) An  irritating  disinfecting 
gas. 

Formalin.  (See  Pharmacology.)  A 
40%  solution  of  formaldehyde  in 
water. 

Fossa.  A  shallow  cavity,  usually 
in  bone. 

Fowler's  position.  (See  p.  170.)  That 
which  imitates  the  upright  sit- 
ting posture  and  secures  isolation 
of  septic  material  in  the  abdomen. 

Fracture.  (See  p.  78.)  A  loss  of 
continmty  of  bony  structure. 

Freniun.  A  fold  of  skin  or  mucous 
membrane  which  limits  the  move- 
ment of  a  structure.  (See 
Anatomy:  tongue,  foreskin,  etc.) 

Frontal.  Pertaining  to  the  frontal 
bone  or  forehead. 

Fulminating.  Coming  on  suddenly 
and  increasing  rapidly  in  inten- 
sity. 


GLOSSARY 


235 


Fumigation.  (See  Hygiene.)  Disin- 
fecting by  the  use  of  gas  or  ma- 
terials which  destroy  micro- 
organisms. 

Function.  The  normal  use  or  ac- 
tion of  a  part  or  organ. 

Functional.  Disease  or  disturbance 
involving  the  function  but  not 
the  structure  of  a  part 

Ftondus.  The  part  of  an  organ  most 
remote  from  its  mouth  or  outlet. 

Fiunincle.  A  boil  or  local  inflam- 
mation involving  the  corium  and 
subcutaneous  tissues,  and  con- 
taining a  definite  "core"  or 
slough  of  necrotic  tissue. 

Fusiform.   Spindle-shaped. 


Gag.      An  instrimaent  for  holding 
the  mouth  open.     Also  refers  to 
unsuccessful  attempts  to  vomit. 
GaU.  ThebUe. 

Gall-bladder  (see  Anatomy  and 
p.  206),  the  sac  which  serves 
as  reservoir  for  the  bile. 
Gall-stones,  calcuh  which  form 
in  the  bile. 
Ganglion.    (See  Anatomy.)  A  group 
of  nerve  cells,  outside  of  the  cen- 
tral nervous  system,  which  serve 
as  a  centre.    Also,  a  cystic  tumor 
or     diverticulum     of    a    tendon 
sheath. 
Gas   bacillus.       (See   Bacteriology 
and    p.    35.)     The   B.    aerogenes 
capsulatus,    which  produces    gas 
in  the  tissues. 

Gas  pains,  those  due  to  dis- 
tention    of     the     intestines 
with    gas    and   painful    per- 
istaltic attempts  to  expel  it. 
Gastric.  Pertaining  to  the  stomach, 

ulcer,  etc. 
Gastritis.       Inflammation    of    the 
mucous  membrane  of  the  stom- 
ach. 

Gastro-intestinal  tract.  The 
alimentary  canal;  including 
the  oesophagus,  stomach, 
small  and  large  intestine, 
and  secretory  organs  open- 
ing into  the  canal. 
Gastro-enterostomy.  (See  p. 
175.)    An  artificial  opening 


made  surgically  between  the 
stomach  and  upper  intes- 
tine. 

Gavage.      Forced   feeding   with   a       i^ 
tube,    usually    by   the    stomach.        ^ 

General.  Involving  the  organism 
as  a  whole,  as  opposed  to  local. 

Genital.  Pertaining  to  the  organs 
of  reproduction  or  generation. 

Genito-urinary.  Pertaining  to  the 
genital  and  urinary  organs. 

Germ.  A  micro-organism  or  seed; 
also  the  early  embryo  or  fertil- 
ized ovmn. 

Germicide.  An  agent  which  de- 
stroys germs. 

Germ-layers.  (See  Embryology.) 
The  primary  tissue  layers  formed 
in  the  early  development  of  the 
embryo. 

Gestation.    Pregnancy. 

Giant-cell.  An  abnormally  large 
tissue  cell.  G.  sarcoma  (see  p.  48) , 
one  composed  largely  of  imusuaUy 
large  connective  tissue  cells. 

Gland.  Any  organ  which  separates 
a  specific  substance  from  the 
blood  in  the  form  of  a  secretion; 
may  be  internal  into  the  blood, 
or  external  through  a  duct  to  a 
surface  or  cavity.  The  term  is 
also  improperly  apphed  to  more 
or  less  discrete  masses  of  tissue, 
lymph-nodes,  in  which  no  such 
fimction  has  been  demonstrated. 

Glanders.  (See  Bacteriology.)  An 
infectious  disease  of  horses,  oc- 
casionally transmitted  to  man. 

Glioma.  A  new-growth  composed 
of  neurogUa-hke  cells  foimd  in  the 
nervous  tissues. 

Glossal.    Pertaining  to  the  tongue. 

Glottis.  The  opening  between  the 
vocal  cords;  also  the  portion  of 
the  larynx  concerned  in  voice 
production. 
Glycerin.  (See  Pharmacology.)  A 
tri-atomic  alcohol  with  marked 
afiinity  for  water,  used  with  tam- 
pons (vaginal)  to  abstract  water 
from  tissues;  also  as  a  vehicle  for 
certain  medicines. 
Goiter.  (See  p.  144.)  An  enlarge- 
ment or  tumor  of  the  thyroid. 


236 


GLOSSARY 


Gonococcus.  (See  Bacteriology 
and  p.  32.)  The  micro-organism 
causing  gonorrhoea. 

Gram's  stain.  An  iodine  stain  used 
in  bacteriological  work  to  differ- 
entiate specific   organisms. 

Granulations.  (See  p.  23.)  A  type 
of  connective  tissue  developing 
in  heahng  wounds. 

Graves's  disease.  Exophthalmic 
goiter.     (See  p.  145.) 

Gravel.  Calcareous  matter  in  the 
kidney  or  bladder  smaller  than 
stones. 

Groin,  A  region  in  the  lower  abdo- 
men at  its  junction  with  the 
thigh. 

Gum.  A  resinous  substance;  ana- 
tomically "gingiva."  The  fleshy 
structure  covering  the  alveolar 
process  and  surrounding  the  teeth. 

Gumma.  A  soft  new-growth  re- 
sembling granulation  tissue,  oc- 
curring in  the  tertiary  stage  of 
syphiUs. 

Gut.    The  intestine  or  bowel. 

Gynecology.  That  branch  of  med- 
icine which  treats  of  women's 
diseases. 

H 

Hasmangioma.  (See  p.  48.)  A  tumor 
composed    of    blood-vessels. 

Haematemesis.  The  vomiting  of 
blood. 

Haematocele.  (Seep.  55.)  A  cavity 
containing  extravasated  blood  or 
sermn  the  result  of  a  broken- 
down  blood-clot. 

Haematoma.  A  sohd  mass  of  coagu- 
lated blood  in  the  tissues. 

Haematuria.  The  presence  of  blood 
in  the  urine. 

Haemophilia.  An  abnormal  tendency 
to  spontaneous  or  excessive 
bleeding,  due  to  delay  in  the  co- 
agulation of  the  blood;  usually 
hereditary,  also  rarely  present 
as  a  temporary  congenital  con- 
dition at  birth.  Also  in  adults  as 
a  result  of  certain  toxEsmias,  re- 
tention of  the  bUe  in  chronic 
jaundice. 

Haemoptysis.  The  spitting  of  blood, 
as  in  pulmonary  tuberculosis. 


Hsemostasis,  The  control  of  hem- 
orrhage. 

Hanging-drop.  (See  Bacteriology.) 
A  drop  of  water  suspended  on  a 
cover-glass  over  a  hollow-ground 
shde,  used  in  bacteriology  to 
study  the  motility  of  micro- 
organisms. 

Hare-lip,  (See  p.  135.)  A  congenital 
deformity  consisting  of  a  cleft  or 
fissure  in  the  upper  hp;  maybe 
single  or  double,  often  associated 
with  a  cleft-palate. 

Haversian  canals,  (See  Anatomy.) 
Minute  canals  in  bone  containing 
nutrient  blood-vessels. 

Hectic,  An  irregular  chronic  fever, 
often  tubercular. 

Hemorrhage,  A  sudden  free  flow 
of  blood. 

Hemorrhoids,  "Piles"  (see  p.  189). 
Submucous  tumors  due  to  dilated 
or  thrombosed  veins  of  the  rec- 
tal mucosa. 

Hemostat.  A  forceps  to  compress 
and  close  a  bleeding  vessel. 

Hepatic.  Pertaining  to  the  Uver, 
"hepar":  ducts,  abscess,  etc. 

Hereditary.  A  condition  which  is 
transmitted  from  parent  to  off- 
spring. 

Hernia.  (See  p.  162.)  The  protru- 
sion of  the  contents  of  a  cavity  or 
vessel  through  an  opening  or 
weakening  in  the  waU. 

Heroin.  (See  Pharmacology.)  A 
hypnotic  drug;  dose  gr.  1/24  to 
1/12. 

Herpes.  (See  Dermatology.)  An 
inflammatory  skin-disease,  char- 
acterized by  the  production  of 
blebs  or  vesicles. 

Hexamethylen-amine.  (See  Phar- 
macology.) A  m-inary  antiseptic; 
dose  gr.  x  to  xx. 

Hiccup,  hiccough.  A  sharp  inspir- 
atory sound  due  to  a  spasm  of  the 
glottis  or  diaphragm. 

Highmore,  antrvun  of.  (See  Anat- 
omy and  p.  131.)  The  bony  cav- 
ity in  the  superior  maxiUa. 

Hiltmi.  The  depression  in  certain 
organs  where  the  nutrient  ves- 
sels enter.  (See  Kidney,  Spleen, 
etc.) 


GLOSSARY 


237 


Hip.    The  region  at  the  side  of  the 
pelvis,  or  about  the  articulation 
of  the  femur  with  the  innominate 
bone. 
Histology.   The  study  of  the  micro- 
scopical structure  of  the  tissues. 
Hodgkin's  disease.   (See  Medicine.) 
A     condition     characterized    by 
chronic  enlargement  of  the  lymph- 
nodes,  local  or  general. 
Hyaline.    (See  Anatomy.)  A  variety 
of  cartilage  covering  the  articular 
surfaces  of  the  bones. 
Hydrocele.      A   circumscribed   col- 
lection of  fluid,  often  in  a  tissue 
space  or  canal,  particularly  the 
inguinal  canal  or  spermatic  cord. 
Hydrocephalus.      (See  p.   103.)    A 
pathological  condition  character- 
ized by  an  abnormal  amount  of 
cerebro-spinal  fluid,  with  dilata- 
tion   of    the    ventricles    of    the 
brain. 
Hydronephrosis.     (See  p.  215.)    A 
coUection  of  urine  in  the  pelvis  of 
the  kidney,  due  to  obstruction  of 
the  xireter. 
Hydrophobia.    (See  special  works.) 
"Rabies,"  a  disease  transmitted 
by  the  bite  of  rabid  animals,  us- 
ually dogs. 
Hydrotherapy.     The  use  of  water 

in  the  treatment  of  disease. 
Hygiene.    The  care  of  the  body  and 

preservation  of  health. 
Hyper-.     Prefix  meaning  above  or 
unusual. 
Hyperalgesia,   excessive   sensi- 
tiveness to  paia. 
Hyperaemia,        an        unusual 

amount  of  blood  in  a  part. 
Hyperemesis,    excessive   vom- 
iting. 
Hyper-nephroma    (see  p.  214), 
a  tumor  derived  from  supra- 
renal tissue. 
Hyper-thyroidism  (see  p.  144), 
an  abnormal  condition  due  to 
excessive  and  atypical  secre- 
tion of  the  thyroid  gland. 
Hypertrophy,  overdevelopment 
of  an  organ  or  tissue,  usually 
in     response     to     increased 
exercise  or  function. 


Hjrpnotic  drug.    One  which  induces 

sleep:  chloral,  veronal,  etc. 

Hypo-.     Prefix  denoting  deficiency 

or  lack  of:  hypo-thyroidism  (see 

p.   143) ;  also,  beneath  or  imder. 

Hypodermic,    under  the    skin 

or  "dermis":  injection. 
Hypodermoclysis,  the  introduc- 
tion of  large  amounts  of  water 
or  other  solutions  under  the 
skin,  to  be  absorbed. 
Hjrpophysis  (see  Anatomy  and 
Physiology  and  page     109), 
an    outgrowth,    particularly 
a  portion  of  brain:  the  pituit- 
ary body. 
Hysterectomy.  The  surgical  remov- 
al of  the  uterus;  may  be  either 
abdominal  or  vaginal. 


Ichthyol.  (See  Pharmacology.)  A 
product  obtained  from  fossil  fish, 
used  in  10%  to  20%  solution  in 
glycerin  to  reheve  pain  due  to 
inflammaition. 

Icterus.    "Jaundice."    (See  p.  200.) 

Ileo.  (See  Anatomy  andp.  185.)  Per- 
taiaing  to  the  "Ueum,"  the  lower 
part  of  the  smaU  intestine. 
Ileo-caecal,  the  junction  of  the 
ileum  and  cecum. 

Ileus.  Refers  to  obstruction  of  the 
bowel.    (See  p.  180.) 

Ihac.  Relating  to  the  "Ilium,"  one 
of  the  bones  of  the  pelvis.  (See 
Anatomy.) 

Immunity.  (See  Hygiene  and  p.  8.) 
The  state  of  being  protected 
from  certain  specific  infections 
or  pathological  processes. 

Immobilize.  To  fix  parts,  especially 
those  of  a  fracture,  in  position. 

Impaction.  (See  Fractures,  p.  79.) 
Firmly  imbedded  or  fixed;  ex- 
ample, when  the  fractured  ends 
of  a  bone  are  driven  together. 

Implantation.  The  grafting  of  a 
part  or  tissue. 

Incarceration.  (See  Hernia,  p.  162.) 
The  fixation  or  imprisonment  of 
a  part  in  an  abnormal  position, 
so  that  it  cannot  be  replaced. 

Incision.  Cutting  into;  a  wound 
made  with  a  sharp  ingtruiaeiit. 


238 


GLOSSARY 


Incontinence.       The    condition    of 
being  unable  to  control  the  evac- 
uations of  the  bladder  or  bowel. 
Paradoxical  I.      (See  p.  216.) 

Incubation,  period  of.  That  from 
the  time  of  exposure  to  a  given 
infection  till  characteristic  symp- 
toms are  present. 

Indigestion.  Properly  refers  to 
imperfect  digestion.  Also  (see  p. 
172)  is  apphed  indefinitely  to  any 
gastro-intestiaal  disturbance. 

Induration.  Hardening,  or  a  mass 
of  hardened  inflamed  tissue. 

Infarction.  (See  Pathology.)  An 
area  of  degeneration  in  an  organ 
or  tissue,  due  to  the  cutting  off 
of  the  blood-supply. 

Infection.  (See  p.  9.)  A  pathologi- 
cal condition  due  to  the  invasion 
of  the  body  with  a  specific  micro- 
organism. 

Infiltration.  The  entrance  into  the 
tissue  ,spaces  or  cells  of  an  ab- 
normal substance,  or  of  an  abnor- 
mal amount  of  a  normal  sub- 
stance :  water,  serum,  fat,  connec- 
tive tissue,  etc. 

Inflammation.  (See  p.  9.)  The 
changes  in  the  body  tissues  which 
occur  as  the  result  of  local  irri- 
tation or  infection. 

Influenza.  (See  Medicine.)  An  acute 
infection  involving  especially  the 
respiratory  tract,  also  other  parts 
of  the  body. 

Infraction.  (See  p.  78.)  An  incom- 
plete fracture,  with  no  displace- 
ment. 

Infra-.    Prefix  meaning  below. 
Infrascapular,  etc. 

Inguinal.  A  region  of  the  lower 
abdomen,   relating  to  the  groin. 

Inhibition.  (See     Physiology.) 

Checking  or  restraining  activity 
of  organs. 

Injection.  The  act  of  forcing  or 
injecting  substances,  usually 
fluids,  into  the  body  tissues,  cav- 
ities, or  vessels;  e.g.,  Hypodermic, 
imder  the  skin;  Intra-uterine, 
into  the  uterus;  Intravenous, 
etc. 

Innocent.  Applied  to  new-growths 
(see  p.  42),  benign,  non-malignant. 


Inoculation.  The  introduction  of 
specific  infectious  material  into 
the  tissues  of  an  individual. 

Inoperable.  Apphed  to  conditions 
which  are  so  far  advanced  that  they 
can  not  be  corrected  by  operation. 

Instrumental.  Accomplished  with 
the  aid  of  instrmnents,  especially 
childbirth. 

Intestinal.  Relating  to  the  small 
and  large  intestine. 

Intoxication.  Poisoning  from  any 
cause. 

Intra-.    Prefix  meaning  within. 
Intra-uterine,  etc. 

Intubation.  (See  special  works  and 
p.  146.)  The  operation  of  intro- 
ducing a  hoUow  tube  into  a  struc- 
ture, especially  the  larynx,  when 
that  structure  is  occluded  by 
diphtheric  inflammation  and  res- 
piration is  obstructed. 

Intussusception.  (Seep.  180.)  The 
invagination  or  shpping  of  a  part 
of  the  intestine  into  the  part  be- 
yond, causing  intestinal  obstruc- 
tion, and  later  strangulation. 

Inunction.  The  act  of  rubbing  an 
oily  medicatioh  into  the  skin,  also 
the  substance  used,  often  mercury 
in  some  form. 

Involuntary.    An  action  performed 
independently  of  the  will  and  be- 
yond one's   conscious   control. 
I.    muscle     (see     Physiology), 
the     non-striated    or    vege- 
tative muscle.  Example:  that 
of  the  intestinal  tract. 

Involucrum.  (See  Pathology  and 
p.  74.)  The  bony  sheath  sur- 
rounding the  cavity  which  results 
from  infection  of  bone. 

Involution.  The  changes  which  an  or- 
gan undergoes  after  fulfilling  its 
function.  Example:  uterus  after 
labor. 

Iodine.  (See  Pharmacology.)  A 
non-metallic  crystalline  element, 
irritating,  used  in  5  to  10%  solu- 
tion (tincture)  in  alcohol,  as  a  local 
antiseptic  and  coimter-irritant. 

Iodoform.  (See  Pharmacology'.)  An 
antiseptic  powder,used  on  gauze  as 
a  dressing  for  wounds,  or  in  oil  as 
an  injection  into  infected  cavities. 


GLOSSARY 


239 


Iris.  (See  Anatomy.)  The  circular 
pigmented  membrane  placed  be- 
tween the  cornea  and  the  lens, 
limiting  the  central  opening  or 
pupil. 

Ischemia.    A  local  anemia. 

Ischiatic.  Pertaining  to  the  ischimn. 
(See  Anatomy  of  the  Pelvis.) 

Ischio-rectal.  The  region  between 
the  rectum  and  the  ischial  bones. 


Jaundice,  "icterus."  (See  p.  200.)  A 
'yellow  pigmentation  of  the  skin 
due  to  the  retention  within  the 
body  of  bile-pigments. 
Jejunum.  (SeeAiiatomyandp.  185.) 
The  upper  three-fifths  of  the  mov- 
able part  of  the  small  intestine. 
Joint,     (See  Anatomy  and  p.  89.) 
Articulation;  the  movable  union 
of  two  or  more  bones. 

False    J.,    abnormal    mobihty 
resulting    from    the    imper- 
fect imion  of  a  fracture. 
Joint-mouse,      an      abnormal 
solid  substance  in  the  cavity 
of  a  joint. 
Jugular  vein.    (See  Anatomy.)  The 
principal  vein  of  the  neck  and 
head.     Pertaining  to  the  region 
of  the  throat. 


Keloid.  A  fibrous  new-growth,  us- 
ually resulting  from  an  overde- 
velopment of  scar  tissue  in  a 
healing  wound. 
Knee.  The  articulation  between 
the  femur  and  tibia.  (See  Anat- 
omy.) 

K.-cap.   The  patella. 
K,-chest     position,    with    the 
patient  resting  on  the  knees 
and  chest;   used  in  gyneco- 
logical     examinations      and 
treatments.     (Fig.  45). 
Kyphosis,      An  angular  deformity 
of  the  vertebral  column,  with  a 
prominence  to  the  back. 


Labiiim,  A  Hp.  Example:  labium 
major  and  minor  of  the  vulva, 
(See  Anatomy). 


Labor.    Childbirth  or  dehvery. 

Laceration.  A  wound  resulting 
from  tearing,  not  having  clean 
cut  edges.  Especially  the  wounds 
of  the  female  perineum  occurring 
in  labor. 

LachrymaL  (See  Anatomy.)  Re- 
ferring to  the  tears. 

Laparotomy, also  Celiotomy.  (Seep, 
161.)  An  operation  made  through 
the  abdominal  wall. 

Lateral,  At  the  side  of;  away  from 
the  mid-line. 

Lavage,  Washing  out  a  cavity, 
particularly  the  stomach. 

Laxative.  A  mild  cathartic. 

Leg.  The  lower  extremity  from 
the  knee  to  the  ankle. 

Lesion.  An  injury,  wound  or  local 
diseased  area. 

Leuksemia.  A  blood-disease  char- 
acterized by  an  anemia  and 
increase  in  the  number  of  white 
blood-cells  or  "leucocytes." 

Leucocytosis.  (See  p.  13.)  The  in- 
crease in  the  number  of  leucocytes 
which  occurs  in  certain  acute 
infections. 

Levator  ani  muscle.  (See  Anatomy.) 
The  pair  of  muscles  which  form 
the  floor  of  the  pelvic  cavity. 

Ligament.  A  band  of  dense  fibrous 
tissue  connecting  the  ends  of  ar- 
ticulating bones,  reinforcing  the 
joint  capsule. 

Ligature.  Thread,  catgut,  or  ma- 
terial used  to  tie  about  blood- 
vessels, and  control  bleeding. 

Limb,  One  of  the  extremities  of  the 
body,  usually  the  lower. 

Line.      Anatomical,    any  structure 
or    attachment     having    length, 
with  only  shght  thickness. 
Linea   alba,     (See   Anatomy.) 
The    fibrous    union    of    the 
sheath  of  the  rectus  abdomi- 
nales  muscles. 
Lingual,     Pertaining  to  or  resem- 
bling the  tongue. 
Liniment,    Any  fluid  to  be  appKed 
to  a  part  by  friction  and  mas- 
sage. 
Lip,  "labium."     A  fleshy  fold  sur- 
rounding the  orifice  of  a  cavity: 
the  mouth. 


240 


GLOSSARY 


Lipoma.    (See  p.  47.)   A  new-growth 

composed  of  fatty  tissue. 
Liquor.   (See  Pharmacy.)  A  solution 
of    a    non-volatile    substance    in 
water. 

L.  cresolis  compound.    Similar 
to    Lysol,  an  antiseptic   de- 
rived   from    crude    carbolic 
acid,  used  in  solution  of  M 
to  3^%. 
Lithiasis.    The  formation  of  calculi 
or  calcareous  concretions  in  the 
body. 
Lithotomy.     A  surgical  incision  of 
the  bladder  for  the  removal  of 
urinary  concretions.    (See  p.  219.) 
Lockjaw.      A   popular    name    for 

"tetanus."    (See  p.  34.) 
Lues.  "SyphiUs."     (Seep.  37.) 
Lordosis.      An   abnormal   anterior 
curvature  of  the  vertebral  column. 
Lumbar.    Pertaining  to  the  region 
of  the  loin. 

L.  puncture.  (Seep.  105.)  The 
insertion  of  a  hoUow  needle 
or  trocar  between  the  lum- 
bar vertebrae,  into  the  sub- 
arachnoid space  of  the  spinal 
cord.  This  may  be  done  for 
diagnosis;  to  study  the  pres- 
sure and  composition  of  the 
cerebro-spinal  fluid;  for 
treatment  to  reheve  increased 
pressure  in  certain  condi- 
tions; to  administer  anti- 
toxrne,  or  drugs,  or  anaes- 
thetics. 
Lupus.        (See    Dermatology.)    A 

chronic  skin-disease. 
Luxation.     Dislocation  of  a  joint. 

(See  p.  90.) 
Lying-in  period.     That  during  con- 
finement and  convalescence. 
Lymph.        (See    Physiology.)    The 
fluid  in  the  tissues  which  is  col- 
lected in  the  Ijmiph-vessels. 
Lymph-nodes.     (See  Anatomy  and 
p.  12.)    Discrete  masses  of  tissue, 
the  cells  of  which  resemble  and 
give  rise  to  the  lymphocjrtes  in 
the  blood. 
Lymphangitis.       An    inflammation 
involving  the  lymphatic  vessels. 
Lymphadenitis.      Inflammation    of 
the  lymph-nodes.    (See  pp.  14, 97.) 


Lysis.  Solution;  the  gradual  recov- 
ery from  a  disease;  fever. 

Lysol.  A  proprietary  preparation 
similar  to  hquor  cresolis  comp. 

M 
Maceration.   Softening,  or  breaking 

down  mechanically. 
Major  operation.      One  which  in- 
volves   extensive  procedures     or 
risk  of  life. 
Malaise.  A  feehng  of  weakness  and 

sickness. 
Malar.    (See  Anatomy.)  The  cheek- 
bone. 
Malaria.     (See  Medictue.)    A  fever 
due  to  infection  by  a  special  para- 
site introduced  by  the  bite  of  the 
female  anopheles  mosquito. 
Malignant.     Bad,  virulent,  threat- 
ening hfe. 

M.  tiunor  (see  p.  43),  one  which 
is  not  encapsulated,  extend- 
ing into  the  neighboring 
tissues,  carried  to  other 
parts  of  the  body,  forming 
metastases,  and  reciu"s  after 
incomplete  surgical  removal. 
Malingerer.  One  who  feigns  sickness 

or  mjury. 
Mallein.     A  specific  antitoxine  for 

glanders. 
Malleolus.         (See    Anatomy.)     A 
small  bony  prominence. 

M.   external  and  internal.  In 

relation   to   the   ankle-joint. 

Mamma.      (See  Anatomy   and  p. 

156.)     The  breast. 
Mammillary  line.    A  perpendicular 
line  extending  through  the  nipple. 
Mandibular.      Pertaining     to     the 

mandible  or  lower  jaw. 
Marrow.  (See  Anatomy  and  p.  74.) 
The  fatty  and  vascular  contents 
of  the   central  cavity  of  bones. 
Also,    the    central  part  of    any 
structure. 
Mastitis.     (See  p.  156.)     Inflamma- 
tion of  breast-tissue. 
Mastoid  cells  or  antnmi.   (See  Anat- 
omy and  p.  131.)  The  cancellous 
bony    process    of    the    temporal 
bone,  behind  the  external  ear. 
Maxillary.    Pertaining  to  the  jaws. 


GLOSSARY 


241 


Meatus.  The  opening  of  a  narrow 
passage:  urinary  of  the  urethra. 

Mediastinum.  (See  Anatomy.) 
The  space  in  the  thoracic  cavity, 
between  the  lungs,  containing 
the  heart,  great  vessels,  trachea, 
and  oesophagus. 

Medicine.  The  general  considera- 
tion and  treatment  of  disease, 
often  limited  to  internal  diseases 
and  those  treated  by  non-opera- 
tive or  non-instrumental  meas- 
\ires,  as  opposed  to  surgical  means. 

MeduUa  oblongata.  (See  Anatomy.) 
That  portion  of  the  brain  contin- 
uous with  the  spinal  cord  below,  the 
cerebellum  and  pons  varolii  above. 

Medullary  marrow.  Central  por- 
tion of  a  structure. 

Melania.  A  black  pigment  found 
in  the  choroid  layer  of  the  eye 
and  in  the  deep  layers  of  the  skin. 
Also  foimd  in  certain  mahgnant 
new-growths,  the  melano-sarcoma. 
(See  p.  48.) 

Membrane.  A  thin  flat  layer  of 
tissue,  surrounding  a  part  or  sep- 
arating structures.  Membrane 
hone.     (See  p.  73.) 

Meninges.  (See  Anatomy  and  p. 
101.)  The  membranes  surround- 
ing the  brain  and  spinal  cord;  in- 
clude the  pia  and  dura  mater, 
and -the  arachnoid. 

Meningocele.  (Seep.  117.)  Ahernial 
sac  through  an  abnormal  opening 
in  the  skull  or  vertebral  column, 
composed  of  one  or  more  layers 
of  meninges  and  containing  cere- 
bro-spinal  fluid. 

Menopause.  The  normal  cessation 
of  the  regular  monthly  menstru- 
ations. 

Menorrhagia.  Excessive  menstrual 
bleeding. 

Mercury.  (See  Pharmacology.) 
Quicksilver,  a  fluid  metalUc  sub- 
stance. Various  preparations  of 
the  metal  and  its  salts  are  used 
medicinally. 

Mesentery.  (See  Anatomy  and  p. 
166.)  A  fold  of  peritoneitm  sur- 
rounding and  suspending  the  in- 
testine and  certain  of  the  abdom- 
inal viscera. 
16 


Mesoderm,  "tnesoblast."  (See  Em- 
bryology.) The  middle  of  the  three 
"primary  germ-layers";  gives  rise 
to  the  vascular,  muscular  and 
supporting  tissues. 

Metabolism.  (See Physiology.)  The 
process  by  which  hving  beings 
transform  foodstuffs  into  tissue 
substance. 

Metacarpal.  (See  Anatomy.)  Per- 
taiuing  to  the  wrist. 

Metamorphosis.  A  change  in 
structure  or  a  degeneration. 

Metastasis.  (See  p.  43.)  A  second- 
ary tumor  or  new-growth,  form- 
ed from  cellular  elements  carried 
in  the  blood  or  lymph  stream. 

Metatarsal.  (See  Anatomy.)  Per- 
taining to  the  ankle. 

Meteorism,  "tympanites."  The 
distention  of  the  abdomen  due 
to  gas  in  the  intestinal  tract. 

Metritis.  Inflammation  of  the 
uterus. 

Metrorrhagia.  Uterine  bleeding  be- 
tween menstrual  periods. 

Microbe.  A  hving  organism  of  mi- 
croscopic size;  bacterium,  micro- 
organism. 

Micturition.  The  act  of  voiding 
lu-ine,  emptying  the  bladder. 

MUk-leg.  (See  p.  95.)  The  swelling 
of  a  hmb  due  to  the  obstruction 
of  the  principal  vein  or  the  lym- 
phatic vessels. 

Minor  operation.  One  involving  only 
simple  procediu-es  and  sUght  risk. 

Miscarriage.  The  expulsion  of  the 
fetus  between  the  fourth  and 
sixth  month  of  intra-uterine  hfe. 
Often  not  thus  limited. 

Mole.  1.  A  bloody  mass  or  degener- 
ated ovum  expelled  from  the 
uterus.  2.  A  type  of  skin-tumor 
composed  of  lymphatic  tissue. 

Montgomery's  glands.  (See  p.  155.) 
Small  sebaceous  glands  in  the 
areola  surrounding  the  nipple, 
most  evident  during  pregnancy. 

Morbidity.  Sickness,  ill-health. 
The  rate  of  sickness. 

Morphine.  (See  Pharmacology.) 
An  alkaloid  derived  from  opium, 
used  to  relieve  pain,  usually  hy- 
podermically;  dose  gv.  }i  to  j4- 


242 


GLOSSARY 


Mortality.  The  death-rate. 

Motile.  Capable  of  spontaneous 
motion. 

Motor  nerves.  Those  which  supply 
voluntary  muscles,  and  which 
when  stimulated  induce  motion. 

Mucosa.  A  membrane  composed  of 
cells  which  secrete  mucus,  a 
viscid  secretion.  (See  Physiology.) 

Mumps.  (See  Medicine  and  p. 
129.)  An  acute  infection  charac- 
terized by  a  non-suppurating 
inflammation  of  the  parotid 
glands. 

Mural.  Pertaining  to  the  wall  of  a 
structiue,  e.g.,  the  uterus. 

Murmur.  A  rough  sound  produced 
by  fluid  flowing  through  an  ir- 
regular opening,  e.g.,  diseased 
heart-valves,  into  an  aneurismal 
cavity. 

Muscle-spasm.  An  involuntary 
contraction  of  a  voluntary  muscle, 
which  protects  an  underlying 
sensitive  part  from  sudden  pres- 
sure. 

Myoma.  (See  p.  47.)  A  tumor  de- 
rived from  muscle  tissue,  usually 
non-striated,  e.g.,  from  the  uterus. 

Myxedema.  (See  p.  143.)  A  patho- 
logical condition  due  to  deficient 
thyroid  secretion.  Characterized 
by  infiltration  of  the  subcuta- 
neous tissue  with  fluid,  and  also 
mental  changes. 

N 

Narcosis.  A  state  of  more  or  less 
complete  unconsciousness  and 
muscular  relaxation,  induced  by 
special  drugs,  Narcotics. 

Nasal.  Pertaining  to  the  nose. 

Naso-pharsmx.  (See  Anatomy.) 
That  part  of  the  pharynx  above 
the  soft  palate  and  continuous 
with  the  nasal  passages. 

Nausea.  A  desire  to  vomit. 

Neck,  "cervix."  Anatomically  lim- 
ited by  the  angle  of  the  jaw  and 
mastoid  above,  and  the  clavicle 
below.  Also  apphed  to  the  nar- 
row portions  of  certain  struct- 
ures,  e.g.,  uterus,   humerus,   etc. 

Necrosis.  (See  p.  10.)  Death  of 
cells  or  tissues. 


Neoplasm.  A  tumor  or  new-growth. 

Neosalvarsan.  (See  Pharmacology.) 
A  proprietary  specific  remedy  for 
syphihs. 

Nephrectomy.  The  surgical  remov- 
al of  a  kidney. 

Nephritis.  Inflammation  of  kidney 
tissue,  usually  non-suppurating. 

Nerve-trunk.  (See  Anatomy  and 
p.  113.)  A  cord-Uke  structure 
composed  of  nerve-fibres  or  axis 
cylinder  processes  from  nerve- 
cells  ("neurones")  and  surround- 
ed by  a  protective  sheath,  capa- 
ble of  transmitting  nerve  impul- 
ses. 

Nerve-centre.  A  group  of  nerve 
cells,  neurones,  which  are  con- 
cerned in  the  supply  of  a  spe- 
cial group  of  muscles  or  a  special 
function. 

Nervous  system.   (See  Anatomy.) 
Central,     includes     the     brain 
and  spinal  cord,   and  sjrm- 
pathetic  gangha. 
Peripheral,  includes  the  vari- 
ous nerve-trunks  in  the  body. 

Neural.  Pertaining  to  the  nervous 
system  or  tissue. 

Neuralgia.  Severe  paroxysmal 
pain  along  the  course  of  a  sensory 
nerve,  the  cause  of  which  is  usu- 
ally not  demonstrable. 

Neuritis.  Inflammation  of  a  nerve- 
trunk,  usuaUy  painful. 

Neuroma.  (See  p.  48.)  A  new- 
growth  in  connection  with  or  de- 
rived from  nervous  tissue. 

Neurone.  A  nerve-ceU.  (See  Anat- 
omy and  p.  98.) 

Nevus.  (See  Pathologj'  and  p. 
48.)  A  circumscribed  area  of  pig- 
mentation; a  new-growth  com- 
posed of  lymph  or  blood-vessels, 
usually  congenital. 

New-growth.  (See'^p.  40.)  Tumors, 
benign  and  mahgnant. 

Nipple.  (See  Anatomy  and  p.  154.) 
The  pigmented  projection  from 
the  surface  of  the  breast,  con- 
taining the  milk  ducts. 

Nitrous  oxide.  (See  Pharmacology 
and  p.  68.)  A  gas  used  to  induce 
narcosis  and  general  anaesthesia. 


GLOSSARY 


243 


Noble's  enema.  One  given  to  stim- 
ulate active  peristalsis  in  certain 
cases  of  suspected  intestinal  ob- 
struction.     Formula: 

Glycerin  2  parts 

Magnesium  sulph.  2  parts 

Water  4  to  8  parts 

Node.    A  small  mass  of  tissue.    Ex- 
ample: IjTnph-node. 
Noguchi's    test.     A  specific   reac- 
tion given  by  individuals  having 
syphilis. 
Noma.     Gangrenous  ulceration  of 

the  mouth. 
Normal.    Usual,  typical. 

N.  saline,  or  salt  solution,  one 
which  contains  the  same  per- 
centage of  sodium-chloride  as 
the  blood  (0.6  per  cent.). 
Novocaine.      (See    Pharmacology.) 
A  derivative  of  cocaine,  used  for 
local    anaesthesia     by    hj^oder- 
mic  or   intraneural    injection  in 
solutions  of  1-500.     Said  to  be 
less  toxic  than  cocaine. 


Obstetrics.  That  branch  of  surgery 
dealing  with  pregnancy  and  chUd- 
bu-th. 

Obstipation.  Extreme  and  persist- 
ent constipation. 

Obstruction.      Hindrance    to    the 
normal  passage  of  the  contents 
of  a  canal; "usually  refers  to 
Intestinal  O.    (See  p.  180.) 

Obturator.  A  plug  or  plate  which 
closes  an  opening.  Example:  as- 
pirating trocar  or  proctoscope. 

Occiput.  (See  Anatomy.)  The  pos- 
terior protuberance  of  the  skuU. 

Occlusion.  The  state  of  being 
blocked,  applied  to  canals  and 
vessels. 

Omentum.  (See  Anatomy  and  p. 
166.)  A  folding  of  the  mesentery. 

Open  fracture.  (See  p.  78.)  One 
which  is  exposed  to  the  air  and 
infection,  i.e.,  not  covered  by 
unbroken  skin  or  mucous  mem- 
brane. 

Operation.  A  therapeutic  measure 
performed  with  instruments  or 
by  the  surgeon's  hands. 


Ophthalmia.  (See  special  works.)  An 
inflammation  , involving  the  eye 
or  the  conjunctival  sac. 

O.  neonatonmi.     (See  p.  33.) 
Ophthalmic.    Pertaining  to  the  eye. 
Ophthalmoscope.      An   instrument 
for   examining  the  retina  of  the 
eye. 
Opisthotonus.     A  form  of  tetanic 
spasm,  characterized  by  a  bend- 
ing of  the  body  so  that  it  rests 
on  the  head  and  heels. 
Opsonins.        (See    special    works.) 
Substances  formed  in  the  blood 
which  are  supposed  to  increase 
the  activity  of  the  white  blood- 
ceUs,_  phagocytes,    in    attacking 
certam  specific  bacteria. 
Organ,  "viscus."  A  group  of  tissues 
in   the   body,    having   a   special 
.'function. 
Organic.     Pertaining  to  an  organ, 
also     to     substances     associated 
with  or  derived  from  organized, 
living  structures. 
Organism.  A  Hving  plant  or  animal. 
Orifice.  The  entrance  or  outlet  to  a 

body-cavity. 
Orthopsedic.    Pertaining  to  the  cor- 
rection of  deformities,  especially 
in  children. 
Os.    A  bone. 

O.  innominatum. 
Osseous.    Composed  of  or  resem- 
bling bone. 
Ossification.     (See  Anatomy.)  The 
formation  or  developmentof  bone. 
Osteitis.    (Seep.  74.)   Inflammation 

of  bone. 
Osteoblast.       (See   p.    73.)    A   ceU 
which  is  specificaUy  active  in  the 
development  of  bone. 
Osteoclast.    An  instniment  used  to 
produce    surgical    fracture    of    a 
bone  to  correct  deformity.    Also 
(see  Anatomy),  the  cells  which  de- 
stroy the  primary  cartilage  bone, 
preceding    the    developement    of 
the  permanent  membrane  bone. 
Osteoma.       (See   p.  47.)     A  new- 
growth  containing  bone-tissue. 
Osteomyelitis.       An   inflammation 
of  bone,  particularly  that  involv- 
ing the  bone-marrow. 


244 


GLOSSARY 


Osteum.  A  mouth  or  opening  to  a 
cavity. 

Otitis.    Inflammation  of  the  ear. 
O.  media,  of  the  middle  ear. 

Ovary.  (See  Anatomy.)  The  special 
female  sex-gland  from  which  the 
ova  are  formed. 

Oviduct.  (See  Anatomy.)  The  fal- 
lopian tubes,  leading  from  the 
cavity  of  the  uterus  to  the  peri- 
toneal cavity  near  the  ovary. 

Ovariotomy.  The  surgical  removal 
of  the  ovary. 

Ovum.  (See  Anatomy  and  Physi- 
ology.) An  egg;  the  female  sex- 
cell,  which  after  fertihzation, 
"conception,"  gives  rise  to  the 
embryo  or  offspring. 

Oxalates.  (See  Physiology.)  Salts 
of  oxahc  acid  formed  in  the  body 
and  excreted  in  the  urine,  nor- 
mally held  in  solution  or  found 
as  crystals.  Pathologically  im- 
portant in  forming  calcuh  or  con- 
cretions. 


Pack.  Treatment  by  wrapping  a  pa- 
tient in  blankets,  dry  or  wet,  either 
hot  or  cold.     (See  special  works.) 

Paget's  disease,  after  a  famous 
English  surgeon.  (Seep.  156.)  An 
eczematous-hke  eruption  about 
the  nipples,  malignant. 

Pain.    Distress  or  suffering. 

Labor  pains  refer  to  contrac- 
tions of  the  uterus  in  con- 
finement, usually  causing 
conscious  pain. 

Palate.    (See  Anatomy  and  p.  135.) 
The  roof  of  the  mouth. 
Soft  P.,  the  uvula. 

Palliative  treatment.  Measures  to 
reheve  symptoms  but  do  not  di- 
rectly influence  the  causal  con- 
dition. 

Pallor.  Paleness;  absence  of  color 
in  the  surface  of  the  bodjj  in  ane- 
mia, or  following  extensive  hem- 
orrhage. 

Palmar.  Referring  to  the  palm  or 
flexor  surface  of  the  hand. 

Palpation.  Examination  of  the  pa- 
tient by  the  hand,  depending  on 
the  sense  of  touch. 


Palpebral.  Referring  to  the  eyelid, 
usually  the  upper. 

Papilla.  A  small  conical  or  nipple- 
Uke  projection  from  an  epithelial 
surface. 

Papilloma.  (See  p.  45.)  A  new- 
growth  from  any  epithelial  surface. 

Para.  A  prefix  meaning  near  or 
associated  with:  para-urethral, 
para-metrium. 

Paracentesis.  The  surgical  punc- 
ture of  a  cavity  (pleural)  with  a 
hollow  needle  or  trocar. 

Paralysis.  Loss  of  the  power  of 
motion. 

Parasite.  An  organism  which  lives 
within  and  at  the  expense  of  an- 
other, the  "host,"  and  usually 
to  the  detriment  of  the  latter. 

Parathyroid  glands.  (See  Phys- 
iology.) SmaU  structures  near  the 
thyroid  having  an  important  in- 
ternal secretion. 

Parenchyma.  The  special  function- 
ing tissue  of  a  structure,  as  op- 
posed to  the  supporting  tissue. 

Parietal.  Pertaining  to  the  wall  of 
a  cavity,  also  parietal  bone  (see 
Anatomy). 

Parotid  gland.  (See  Anatomy.)  The 
salivary  gland  located  in  the  cheek. 

Parturition.  The  process  of  child- 
birth. 

Paste.  (See  Pharmacology.)  A 
semi-fluid,  viscous  substance, 
usually  containing  a  medicine. 
Example:  Beck's  paste,  contain- 
ing bismuth  in  vaseline. 

Pasteur  treatment.  A  specific  treat- 
ment for  hydrophobia,  named  for 
Louis  Pasteur,  a  famous  French 
scientist. 

Patella.  (See  Anatomy.)  The  knee- 
cap. 

Patent.  Open,  patulous;  applied 
to  a  canal  or  vessel. 

Pathogenic.  A  micro-organism 
causing  disease. 

Pathognomonic.  A  symptom  or  a 
sign  pointing  directly  to  a  spe- 
cific cause  or  disease. 

Pathology.  That  branch  of  medi- 
cine which  treats  of  abnormal 
tissue  changes  and  structural 
causes  of  disease. 


GLOSSARY 


245 


Pedicle.  A  narrow  portion  of  a 
tumor  containing  the  nutrient 
vessels  and  nerves,  serving  as  the 
attachment  of  the  tumor. 

Pedunculated.  A  mass  attached  by 
a  pedicle,  or  peduncle.    (See  p.  45.) 

Pelvis.  A  basin-like  structui'e;  un- 
less qualified,  refers  to  the  bony 
structure  formed  by  the  sacrum 
and  innominate  bones.  (See  Anat- 
omy).   Also, 

Kidney  P.  (see  Anatomy  and 
p.  207),  the  sac  or  collecting 
portion  of  the  kidney,  con- 
tinuous  with    the    m-eter. 

Per.   Prefix  meaning  through  or  by 
way  of. 
P.  anum,  given  by  the  anus. 

Peri.  Prefix  meaning  about  or  sur- 
rounding.   Perirectal  fat. 

Pericardium.  (See  Anatomy  and 
p.  154.)  The  serous  sac  surround- 
ing the  heart. 

Perichondrium.  (See  Anatomy.) 
The  fibrous  and  nutrient  mem- 
brane surrounding  cartUage. 

Perineum.  (See  Anatomy.)  The  re- 
gion between  the  anus  and  the 
external  genitals. 

Periosteum.  (See  Anatomy  and 
p.  73.)  The  fibrous  and  nutrient 
membrane  surrounding  bone. 

Periostitis.  (See  p.  75.)  Inflamma- 
tion of  the  periosteum  and  under- 
lying bone. 

Peripheral,  Away  or  remote  from 
the  centre.    Peripheral  nerves. 

Peristalsis.  (See  Physiology.)  The 
rhythmical  contractions  of  the 
muscles  of  the  hollow  viscera, 
gastro-intestinal  tract,  by  which 
the  contents  are  carried  through 
to  the  rectum. 

Peritonetun.  (See  Anatomy  and 
p.  165.)  The  serous  membrane 
lining  the  abdominal  cavity,  cov- 
ering certain  organs,  and  forming 
folds,  mesentery  and  omentum. 

Peritonitis.  (See  p.  167.)  An  in- 
flammation involving  the  peri- 
toneum. 

Peroxide.  (See  Pharmacology.) 
Any  oxide  which  contains  oxygen 
easily  given  off  imder  favorable 
conditions. 


Hydrogen  p.,  H2O2,  which  gives 
off  an  atom  of  oxygen  in  the 
presence  of  organic  matter, 
blood. 

Pessary.  An  instrmnent  to  be  re- 
tained in  the  vagina  for  the  pur- 
pose of  supporting  the  uterus. 

Phagedena.  A  rapidly  spreading 
ulcer. 

Phagocyte.  Leucocyte,  a  blood-cell 
which  destroys  micro-organisms 
or  foreign  bodies  in  the  tissues. 

Phalanx.  (See  Anatomy.)  One 
of  the  bones  of  the  fingers  or 
toes. 

Pharyngitis.  An  inflammation  of 
the  pharynx.  (See  Anatomy  and 
p.  137.) 

Phenol.    Carbolic  acid. 

Phlebitis.  Inflammation  involving 
or  extending  along  a  veia. 

Phlebotomy.  Incision  into  a  vein; 
bleeding. 

Phlegmasia.  Thrombosis.  (See  p. 
95.) 

Phlegmon.  A  form  of  abscess  in 
connective  tissue. 

Phthisis.  Wasting  of  the  body;  usu- 
ally refers  to  pulmonary  tuber- 
culosis. 

Pia  mater.  (See  Anatomy.)  The 
inner  layer  of  the  meninges. 

Pigment.  A  coloring  matter,  usually 
derived  from  the  blood. 

Piles.  A  popular  term  for  hemor- 
rhoids. 

Pimple.  (Seep.  11.)  A  small  local- 
ized infection  ia  the  skin. 

Pituitrin.  (See  Pharmacology.)  An 
active  principle  derived  from  the 
pituitary  gland,  used  hypoder- 
mically  to  stimulate  contractions 
of  involuntary  muscle :  the  uterus 
during  labor  or  the  intestine  in 
post-operative  xlistention. 

Plantar.  Refers  to  the  sole  of  the 
foot. 

Plasmodium.  A  form  of  blood  par- 
asite. 

Plaster.  A  tenacious  substance  for 
spreading  on  the  surface  of  the 
body:  for  mechanical  support, 
adhesive;  counter-irritation,  mus- 
tard, etc. 


246 


GLOSSARY 


Plaster  of  paris  bandage.  Gauze 
bandage  impregnated  with  calcium 
sulphate,  put  on  wet  and  allowed 
to  harden,  forming  a  rigid  dress- 
ing for  fractures. 
Plastic  operation.  One  which  repairs 

loss  of  tissue  or  deformity. 
Pleurisy.    An  inflammation  involv- 
ing the  pleura   (see  p.  153),  the 
serous     membrane     surrounding 
the  lungs. 
Pneumonia.     (See   Medicine.)     An 
inflammatory    process    involving 
the  tissue  of  the  lungs. 
Pneumo-thorax.     (See  p.  151.)  An 
opening  between  the  pleural  cav- 
ity and  the  exterior  or  the  bron- 
chial passages. 
Pneumococcus.    (See  p.  33.)   A  va- 
riety of  bacteria. 
Polypus,  polyp.    (See  p.  45.)   A  ped- 
unculated growth  from  a  mucous 
surface,  protruding  into  a  cavity 
or   passage:   bladder,    uterus,    or 
nasal  passage. 
Pons  varolii.     (See  Anatomy.)  The 
portion  of  the   brain  below  the 
cerebrum  and  in  front  of  the  cere- 
bellum. 
Portal.    Pertaining  to  the  hver  and 
portal  circulation. 

P.  of  entry  (see  p.  7),  the  pri- 
mary focus  of  an  infectious 
process. 
Position.     A  special  attitude  of  a 
patient  for  examination  or  treat- 
ment:    Fowler's,     Sim's,     knee- 
chest,  etc. 
Posterior.     Situated  behind  or  at 

the  rear. 
Post.     Following  or  after. 

Post-mortem,  after  death,   or 

autopsy. 
Post-operative,  after  operation. 
Post-partum,  folio  wing  delivery. 
Potassium.     (See  Pharmacy.) 

P.  iodide,  a  salt  used  in  the 
specific   treatment  of  S3^h- 
iLis. 
P.  permanganate,  an  oxidizing 
germicide   used  in  solutions 
of  1  to  5000  to  1  to  10,000. 
Pott's  disease.    (See  p.  75.)  Tuber- 
culosis of  the  vertebral  column. 


Pott's  fracture  (see  p.  88),  that 
involving  the  lower  end  of 
the  fibula  above  the  exter- 
nal malleolus. 

Poupart's  ligament.  (See  Anatomy.) 
That  extending  from  the  ante- 
rior superior  spine  of  the  ilium  to 
the  sine  of  the  pubes,  in  relation 
to  the  inguinal  canal  (seep.  165). 

Predisposition.  A  special  individ- 
ual tendency  to  some  particular 
disease. 

Premature.  Occurring  before  the 
proper  time. 

Preventive.  Treatment  or  measures 
taken  to  avoid  the  occurrence  of  a 
particular  condition. 

Probang.  A  flexible  rod,  with  spe- 
cial apparatus  at  the  end  for  en- 
gaging foreign  bodies,  especially 
in  the  throat. 

Probe.  A  slender  flexible  blunt  in- 
strument for  exploring  sinuses  or 
cavities. 

Procto.  Referring  to  the  rectum  or 
lower  bowel. 

Proctoclysis,  the  injection  of 
fluid  into  the  rectum  by  the 
drop  method,  to  be  retained. 

Proctoscope.  An  instrmnent  which 
exposes  the  mucosa  of  the  rectiun 
for  examination. 

Prodrome.  A  characteristic  symp- 
tom which  occurs  early  in  the 
course  of  a  disease. 

Prognosis.  A  judgment  concerning 
the  probable  outcome  of  a  path- 
ological condition. 

Prolapse.  A  falling  or  dropping  of 
an  organ  or  structure  from  its 
normal  position. 

Pronation.  The  position  of  the 
forearm  with  the  palm  of  the 
hand  upward. 

Prophylactic.  Preventive  measm-es 
taken  to  ward  off  disease. 

Prostate.  (See  Anatomy.)  A  gland- 
ular structure,  present  in  the  male, 
surrounds  the  urethra  atthebaseof 
the  bladder.  Enlargement  or  hy- 
pertrophy is  not  infrequent  in  mid- 
dle-age and  causes  obstruction  to 
the  complete  emptying  of  the  blad- 
der, resulting  in  the  accumulation 
oi  residual  wxixiQ  (see  p.  220). 


GLOSSARY 


247 


Proud  flesh.  (Seep.  23.)  Excessive 
collections  of  exuberant  granu- 
lations. 

Ptosis.  (See  p.  160.)  A  falling  or 
sagging  of  a  part.  Intestine, 
stomach,  etc. 

Puberty.  That  period  of  life  dur- 
ing the  development  of  the  gen- 
erative organs,  from  12  to  14 
years. 

Pubes.  (See  Anatomy.)  The  region 
of  the  symphysis  or  articulation 
of^the  pubic  bones. 

Puerperixun.  The  period  including 
childbirth  and  recovery. 

Pulmonary.  Referring  to  the  lungs 
and  respiratory  tract. 

Pulse.  (See  Physiology.)  The  wave 
of  increased  pressure  due  to  the 
contraction  of  the  heart,  and 
which  is  transmitted  through  the 
systemic  arteries. 

Puncttured  wound.  (See  p.  50.) 
One  made  with  a  sharp  piercing 
instrmnent. 

Pupil.  The  clear  space  at  the  cen- 
tre of  the  iris  of  the  eye,  through 
which  hght-waves  reach  the  sen- 
sitive retina. 

Purulent.  Fluid,  serum,  or  dis- 
charge which  contains  pus  visi- 
bly. 

Pus.  (See  p.  10.)  Necrotic  white 
blood-cells;  also,  tissue  cells  de- 
stroyed by  infection. 

Pustule.  A  local  infection  in  the 
skin  contaitdng  pus. 

Putrefaction.  Abnormal  decompo- 
sition of  organic  substances. 

Pyelitis.  Inflammation  of  the  kid- 
ney pelvis  (see  p.  211). 

Pyuria.  Pus  in  the  urine. 

I^orrhea  alveolaris.  (See  p.  134.) 
Infection  about  the  roots  of  teeth 
in  the  alveolar  process.  Riggs's 
disease. 

Pylorus.  (See  Anatomy.)  That 
part  of  the  stomach  continuous 
with  the  duodenum  (see  p.  174). 

Pyonephrosis.  Suppuration  with 
accumulation  of  purulent  ma- 
terial in  the  kidney  pelvis  (see 
p.  211). 


Quinine.     (See  Pharmacology.)    A 
bitter    alkaloid    used    in    febrile 
attacks,    a   specific  for  malaria. 
Q.    and    urea    hydrochloride. 
(See  p.  69.)     Used  hypoder- 
mically  or    intra-muscularly 
for  local  ansesthesia. 
Quinsy.    Suppuration  and  abscess- 
formation  about  the  tonsU. 


Rabies,  "hydrophobia."  (See  spe- 
cial works.) 

Radial.  Pertaining  to  the  radius 
and  that  part  of  the  forearm. 

Radiogram,  "skiagram."  A  pho- 
tographic plate  exposed  to  the 
Rontgen  rays. 

Ranula.  (See  p.  137.)  A  cystic  tu- 
mor beneath  the  tongue,  due  to 
the  occlusion  and  dilatation  of  the 
duct  from  the  sahvary  gland. 

Reaction.  The  response  of  a  part 
or  organ  to  stimulation;  also,  a 
chemical  change. 

Rectum.  (See  p.  186.)  The  lower 
fixed  portion  of  the  large  intes- 
tine below  the  sigmoid,  opening 
at  the  anus. 

Rectus.     Straight  perpendicular. 
R.    abdominis    (see    Anatomy 
and  p.  159),  one  of  the  mus- 
cles of  the  abdominal  wall. 

Reduction.  The  restoration  of  a  dis- 
placed part  to  its  normal  position. 
Example:  a  fractured  bone,  dis- 
located joint,  hernial  protrusion. 

Reflex.  (See  Physiology.)  An  in- 
voluntary response   to  stimulus. 

Regurgitation.  A  backflow  or  re- 
versal of  the  course  of  fluid  con- 
tents in  the  gastro-intestinal 
tract  or  blood-vessels. 

Renal.    Pertaining  to  the  kidney. 

Resection.  The  surgical  removal 
of  a  part  or  organ. 

Residual.  The  part  retained  within 
a  cavity  after  voluntary  expul- 
sion.   Example:  residual  urine. 

Resolution.  The  return  of  tissues  to 
normal  after  physiological  activity , 
pregnancy;  or  pathological  proc- 
esses, the  lung  after  pneumonia,  or 
tissues  after  an  abscess.  (Seep.  10.) 


248 


GLOSSARY 


Retro-.  Prefix  meaning  behind,  or 
at  the   rear  of.     Retroperitoneal. 

Rhachitis,  "rickets."  (See  Medi- 
cine.) A  constitutional  disease  of 
early  childhood,  characterized 
by  defective  bone-formation  and 
later  deformities. 

Rheiunatism.  (See  Medicine.)  A 
specific  infection.  Improperly 
apphed  to  numerous  conditions 
associated  with  pain  in  the  mus- 
cles or  joints. 

Rib.  (See  Anatomy  and  page  150.) 
Floating  ribs,  the  two  lower 
pairs  which  are  imattached 
at  their  anterior  ends. 

Riggs's  disease.  Pyorrhoea  alveola- 
ris.    (See  p.  134.) 

Ring.  A  normal  opening  through  a 
muscular  wall :    Inguinal. 

Rongeur  forceps.  An  instrument 
used  to  bite  off  and  remove  bone. 

Round  ligament.  (See  Anatomy.) 
One  of  the  Hgaments  of  the  uterus. 

Rupture.  A  forcible  tearing  of  a 
structure:  also,  refers  to  hernia. 

Rudimentary.  An  organ  or  part 
which  is  not  functioning  and  is 
degenerated. 

S 

Sacro-iliac.  (See  Anatomy.)  Relat- 
ing to  the  articulation  of  the 
sacrum  and  ihum. 

Saline.  Salty  compounds,  especially 
those  of  sodium,  magnesium,  and 
potassium.  Also,  normal  sodium- 
chloride  solution. 

Saliva.  (See  Physiology.)  The 
mixed  secretion  of  the  parotid, 
sublingual,  and  submaxillary 
glands. 

Salivation.  A  condition  due  to 
poisoning  with  mercury,  charac- 
terized by  tender  gums  and  ex- 
cessive flow  of  saKva. 

Salol.  (See  Pharmacy.)  A  com- 
pound of  phenol  and  saHcyhc 
acid. 

Salpingo.  Relating  to  the  fallopian 
tubes;  also  the  Eustachian  tubes. 

Salvarsan.  (See  Pharmacology.)  A 
proprietary  preparation  used  in 
the  specific  treatment  of  syphilis. 


Sapremia.  A  mild  febrile  condition 
due  to  the  absorption  of  toxic 
substances  (ptomaines)  from  pu- 
trefaction, possibly  low-grade  in- 
fection. 

Saprophytic.  (See  Bacteriology.) 
Micro-organisms  which  grow  in 
dead  organic  material. 

Sarcoma.  (See  p.  48.)  A  mahgnant 
new-growth  derived  from  and 
resembling  some  type  of  connec- 
tive tissue. 

Scab.  (See  p.  43.)  A  crust  formed 
by  the  drying  of  secretions  cov- 
ering an  ulcerating  area. 

Scalp.  (See  p.  116.)  The  skin  and 
subcutaneous  tissue  covering  the 
vault  of  the  skull,  the  hair- 
bearing  area. 

Scalpel.  A  small  knife  having  a  con- 
vex cutting  edge. 

Scar.     (See  p.  50.)     "Cicatrix." 

Sciatic  nerve.  (See  Anatomy.) 
The  motor  and  sensory  nerve  in 
the  posterior  part  of  the  thigh, 
supplying  the  leg  and  foot.  Also 
refers  to  the  region  where  the 
nerve  passes  through  the  pelvis. 

Scirrhus.  A  form  of  hard  tough 
cancer. 

Sclera.  (See''Anatomy.)  The  dense 
white  portion  of  the  eyeball. 

Sclerosis.  (See  Pathology.)  A 
hardening,  usually  with  degener- 
ation and  infiltration  of  the  tissues 
with  fat  and  calcium  deposit. 

Scoliosis.  (See  p.  150.)  A  lateral 
curvature  of  the  vertebral  col- 
umn. 

Scrottmi.  (See  Anatomy.)  The 
pouch,  composed  of  skin,  connec- 
tive tissue  and  fascia,  which  con- 
tains the  testicles. 

Scybala.   Hard  fecal  masses. 

Searcher,  stone.  A  hollow  me- 
tal tube  or  probe  introduced 
through  the  vuethra  into  the 
bladder,  to  detect  the  presence 
of  calculi. 

Sebaceous  glands.  Those  about 
the  hair  folhcles,  having  a  char- 
acteristic secretion,  sebum. 

Section.  Cutting,  abdominal  sec- 
tion, laparotomy. 


GLOSSARY 


249 


Secretion.     A  substance  which  is 
separated  from  the  blood  by  the 
specific  action  of  certain  tissues, 
usually   collected   in   ducts   and 
carried  into  a  cavity  of  the  body 
for  a  special  purpose;  or  is  car- 
ried to  the  surface  as  a  waste 
excretion. 
Internal  S.,  one  which  is  taken 
up  by  the    circulatiag  blood 
or  body  fluids  and  has  met- 
aboUc  influence. 
Sedative.     Quieting,  lesseniag  func- 
tional activity. 
Sepsis.     (See  p.  9.)     The  morbid 
general    condition   produced    by 
local  infection. 
Septic.     Due  or  related  to  sepsis. 
Also,  any    material    capable    of 
causing  sepsis. 
Septum.     A  partition  or  dividing 
wall  between  two  cavities  or  pas- 
sages. 
Sequela.    A  pathological  condition 
following  and  directly  due  to  some 
particular  disease. 
Serous.    Pertaining  to  or  secreting 

serum,  or  similar  fluids. 
Serum.       (See    Physiology.)      The 
clear    fluid    separated    from    the 
blood. 
Sessile.    (See  p.  45.)  A  mass  or  tu- 
mor which  has  a  broad  attach- 
ment and  is  not  pedunculated. 
Shin.     The  anterior  tibial  region  of 

the  leg. 
Shock.     (See  p.  63.)    A  sudden  de- 
pressed general  condition  affect- 
ing the  circulatory  system. 
Sigmoid.     An  S-shaped  structure. 
S.  flexure    (see   Anatomy),   a 
movable   loop  of   the   large 
intestine,  above  the  rectum. 
Sign,  physical.  An  objective  change 
or  reaction  in  a  patient  which  can 
be  demonstrated  by  physical  ex- 
amination,   indicating   abnormal 
conditions. 
Sims.    An  American  gjniecologist. 
Sims's  position,  the  semi-prone, 
on   the   left   side,    with   the 
right  knee  and  thigh  drawn 
upward     and     the     patient 
resting  forward  on  her  chest. 
(See  Fig.  46.) 


Sims's  speculimi,  for  vaginal 
examination. 

Sinus.  A  hoUow  cavity.  1.  Cer- 
tain spaces  in  cancellous  bone, 
especially  in  the  skull.  (See  Anat- 
omy). 2.  Large  venous  spaces  in 
the  cerebral  circulation,  also  other 
regions.  (See  Anatomy.)  3. 
(See  p.  19.)  A  tract  leading  from 
a  suppurating  cavity  to  the  sur- 
face. 

Sitz  bath.  A  hip-bath.  (See  special 
works.) 

Skin.  (See  Anatomy  and  p.  5.) 
Skin-grafting.  The  use  of  flaps 
or  bits  of  skin  to  cover  a 
granulatiag  wound,  or  an 
area  where  the  skin  has  been 
destroyed  (burns)  or  re- 
moved (extensive  operation 
of  cancer). 

Skiagraphy.  The  use  of  the  Rontgen 
or  X-rays  for  making  fluoroscopic 
examination  of  deep  structures, 
or  for  taking  photographic  plates. 

Slide.  Thin  plate  of  glass  to  mount 
preparations  for  microscopic 
study. 

Slough.  A  mass  of  dead  tissue,  the 
result  of  necrosis  or  gangrene. 

Smear.  A  thin  layer  of  blood,  se- 
cretion, or  discharge  prepared  on 
a  shde  for  microscopic  study. 

Sound.  1.  A  characteristic  noise  pro- 
duced by  some  body  fimction 
(example :  the  closure  of  the  valves 
of  the  heart),  and  heard  through 
the  wall  of  the  body  by  means  of 
a  special  instrument,  stethoscope. 
2.  An  instnmaent  or  probe  used 
to  explore  narrow  passages  or 
cavities  of  the  body  to  detect 
foreign  bodies,  constrictions,  or  to 
dilate  the  latter. 

Spasm.  A  sudden  and  more  or  less 
involuntary  muscular  contraction. 

Spastic.  Pertaining  to  or  resembling 
a  spasm. 

Specific.  Having  a  single  definite 
cause  or  action,  e.g.,  typhoid;  also 
conunonly  applied  to  syphilitic 
infection.  A  drug  which  is  accept- 
ed as  a  definite  cure  for  certain 
conditions. 


250 


GLOSSARY 


Speculum.  An  instrument  to  open 
or  dilate  the  orifice  of  a  canal  or 
body  cavity,  vagina,  or  rectum 
for  visual  examination  and  treat- 
ment. 

Spermatic  cord.  (See  Anatomy.) 
The  cord-like  collection  of  vessels, 
nerves  supplying  the  testicle,  in- 
cluding the  vas  deferens,  or  duct 
which  transmits  the  semen. 

Sphincter.  A  circular  muscle  sur- 
rounding and  closing  an  orifice: 
anus. 

Spinal.     Referring  to  the  vertebral 
colmnn. 
S.   cord,   that  portion  of  the 
central  nervous  system  con- 
tained in  the  vertebral  col- 
umn. 

Spindle  cell.  A  type  of  embryonic 
connective-tissue  cell  found  in 
certain  sarcomata. 

Spine,  A  sharp  bony  process.  Also 
refers  to  the  spinal  column. 

Spirilum.  (See  Bacteriology.)  A  type 
of  bacteria. 

Spirochseta.  A  genus  of  micro-or- 
ganism. SpirochoBta  pallida,  the 
specific  causal  organism  of  syph- 
ilis. 

Splanchnic.  Pertaming  to  the  vis- 
cera. 

Splenic.  Pertaining  to  or  associated 
with  the  spleen 

Splint.  A  rigid  support  or  dressing 
to  immobilize  a  part.  Composed 
of  wood,  metal,  or  plaster  of  paris. 

Sponge.  A  pad  of  sterUized  absorb- 
ent gauze  used  in  surgical  opera- 
tions. 

Sporadic.  Refers  to  occasional  or 
scattered  cases  of  an  infectious 
disease. 

Spore.  (See  Bacteriology  and  p.  2.) 
A  form  of  bacteria  which  is  tem- 
porarily inactive,  and  unusually 
resistant  to  destructive  agents. 

Sprain.  A  wounding  or  tearing  of 
Ugaments  or  tendons. 

Squamous.  (See  Histology.)  Scale- 
like; a  type  of  epithehum. 

Stain.  Pigment  used  to  color  prep- 
arations  for   microscopic   study. 

Staphylococcus.  (See  Bacteriology 
and  p.  31.)    A  variety  of  bacteria. 


Stasis.  Delay  or  blocking  of  the 
passage  of  contents  in  a  canal, 
intestine. 

Stenosis.  A  pathological  narrowing 
of  a  canal  or  orifice. 

Sterile.  (See  p.  3.)  Not  capable  of 
reproducing;  also,  free  of  bacteria. 

Stertorous.  A  type  of  breathing 
characterized  by  snoring,  due  to 
unusual  relaxation  of  the  volun- 
tary muscles  of  the  tongue  and 
throat.  (See  Deep  Narcosis  and 
Coma.) 

Stethoscope.  An  instrument  to 
transmit  and  intensify  the  sounds 
produced  in  the  body,  used  in 
physical  examination. 

Sthenic.    Strong,  active. 

Stimulate.  To  excite  or  cause  body 
activity. 

Stitch  abscess.  (See  p.  6.)  An  ab- 
scess which  forms  about  a  sutiure 
which  penetrates  the  skin. 

Stoma.    Mouth. 

Stomatitis.  An  inflammation  or  ul- 
ceration about  the  mouth. 

Stool.   Evacuation  of  the  bowels. 

Strangulated,  "choked."  So  com- 
pressed that  the  blood-supply  is 
cut  off  or  interfered  with. 

Streptococcus.  (See  Bacteriology 
and  p.  31.)   A  variety  of  bacteria. 

Stroma.  The  supporting  frame- 
work of  a  glandular  structure. 

Stropanthin.  (See  Pharmacology.) 
An  alkaloid  used  hypodermically 
as  a  cardiac  and  circulatory  stim- 
ulant, gr.  1/300  to  1/200. 

Strychnine.  (See  Pharmacology.) 
An  alkaloid  used  hj^odermicaUy 
as  a  stimulant.  Dose  gr.  1/60  to 
1/30. 

Stupes.  Hot  moist  pads,  appUed  to 
the  abdomen  to  stimulate  the 
passage  of  flatus  or  to  relieve  pain. 

Stupor.  A  condition  of  partial  vm- 
consciousness. 

Sub-.  A  prefix  denoting  vmder  or  be- 
low.  Example:  subarachnoid,  etc. 

Subluxation.  A  dislocation  in  which 
the  displaced  bone  has  been  re- 
duced spontaneously,  but  has 
injured  the  joint  capsule. 

Subnormal.  Below  the  normal 
standard. 


GLOSSARY 


251 


Supination.  The  position  of  the 
forearm  with  the  palm  of  the  hand 
down. 

Suppository.  A  sohd  medicated  sub- 
stance, gelatin  or  cocoa-butter, 
to  be  introduced  into  the  rectum 
or  vagina,  and  absorbed. 

Suppuration.  (See  p.  10.)  The  for- 
mation of  pus. 

Supra-.    A  prefix  denoting  above. 
Suprarenal     body     or    gland, 
(see  Anatomy),  a  glandular 
structin-e  having  an   impor- 
tant internal  secretion. 

Suprarenalin,  also  Adrenalin. 

Surgical.  Referring  to  pathological 
conditions  which  are  treated  by 
mechanical  or  instrumental  means 
as  opposed  to  medical,  those  treat- 
ed by  hygiene,  diet,  or  medicines. 

Suture.  1.  Anatomical,  the  hne  of 
fusion  of  the  bones  of  the  skull. 
2.  A  stitch  or  series  of  stitches  used 
to  approximate  the  edges  of  a 
woimd,  or  the  material  used  for 
this  purpose. 

Symptom.  A  subjective  change  in 
the  condition  of  a  patient  as  a 
result  of  disease,  e.g.,  pain,  vom- 
iting, etc. 

Syncope.  A  sudden  faintness  or 
loss  of  consciousness. 

Syndrome.  A  characteristic  group 
of  symptoms. 

Synovia.  The  viscous  secretion  of 
the  synovial  membrane  of  a  Joint- 
cavity. 

Synovitis.  Inflammation  of  a  syn- 
ovial membrane. 

Syphilis.  (See'p.  37.)  A  specific  in- 
fection, usually  venereal. 

Syringe.  An  apparatus  for  injecting 
fluid.  Aspirating  s.,  one  used  to 
withdraw  fluid  from  a  cavity. 

Systemic.  Pertaining  to  the  entire 
system  or  organism. 


Tampon.  A  packing  or  compress  of 

gauze  or  cotton. 
Tapping,  also  Paracentesis. 
Tarsal.      Pertaining  to  the   tarsal 

bones  of  the  wrist. 
Temperature.    The  degree  of  heat 

of  the  body.   Not  a  fever. 


Tendon.  The  fibrous  portion  of  a 
muscle,  which  is  attached  to  bone. 

Tenesmus.  Contraction  of  invol- 
untary muscle  associated  with 
pain;  painful  micturition  or  de- 
fecation. 

Terminal  circulation.  That  having 
no  anastomoses  or  co-lateral  cir- 
culation, representing  the  sole 
blood-supply  to  a  part.  (See  p.  93.) 

Tertiary.  Usually  refers  to  the 
third  stage  of  syphilis. 

Testicle.  (See  Anatomy.)  The  spe- 
cial sex-organ  of  the  male. 

Tetanus.  (See  p.  34.)  An  infectious 
process  introduced  into  wounds 
and  characterized  by  tonic  con- 
tractions  of   voluntary   muscles. 

Tetany.  A  condition  characterized 
by  spastic  contractions  of  the 
voluntary  muscles. 

Theca.  (See  Anatomy.)  A  tendon 
sheath. 

Therapeutics.  Therapy,  any  form 
of  treatment  used  in  the  care  of 
disease. 

Thigh.  The  lower  limb  from  the 
pelvis  to  the  knee. 

Thrombosis.  (See  p.  95.)  The  co- 
agulation of  blood  in  a  vessel, 
usually  a  vein. 

Thymus.  (See  Anatomy  and  p.  154.) 
A  glandular  structure  located  in 
the  thorax,  above  the  heart  and 
in  front  of  the  trachea. 

Thyroid.  (See  p.  143.)  A  ductless 
gland  situated  in  the  neck. 

Thyro-glossal  duct.  (See  p.  143.) 
The  remnant  of  an  embryonic 
structure  extending  from  the 
thyroid  gland  to  the  base  of  the 
tongue. 

Tibial.  Referring  to  the  tibia,  the 
larger  bone  of  the  leg. 

Tincture.  (See  Pharmacology.)  A 
preparation  of  a  medicinal  sub- 
stance in  an  alcohoUc  solution. 

Tissue.  (See  Histology.)  A  collec- 
tion of  similar  cells  having  a  com- 
mon function. 

Tone.  The  normal  physiological 
condition  of  the  body. 

Tongue.  (See  Anatomy  and  p. 
136.) 


252 


GLOSSARY 


Tongue  depressor.  A  metal  or  wood- 
en spatula  to  compress  the 
tongue  and  expose  the  throat  for 
examination. 

T.  forceps,  a  special  instrument 
to  grasp  the  tongue  without 
tearing,  to  draw  it  forward 
during  deep  narcosis. 
Tongue-tied  (see  p.  136), 
characterized  by  the  presence 
of  a  short  frenum  which 
limits  the  movement  of  the 
tip  of  the  tongue. 

Tonic.  Relating  to  the  normal  tone 
of  the  tissues ;  also,  a  medicine  sup- 
posed to  aid  in  restoring  normal 
tone  to  the  body  functions. 

Tonsillectomy.  The  siu-gical  removal 
of  the  tonsils.    (See  p.  138.) 

Torsion.  The  twisting  of  a  pedicle 
in  such  a  manner  as  to  cut  off  the 
blood-vessels. 

Tourniquet.  (See  p.  52.)  A  bandage, 
usually  elastic,  used  to  constrict 
and  surround  a  part  and  control 
hemorrhage. 

Toxsemia.  (See  p.  13.)  A  general 
condition  due  to  the  absorption 
into  the  body  of  poisonous  sub- 
stances: toxines  from  a  local  ne- 
crotic  or  inflammatory  process. 

Tracheotomy.  (See  p.  147.)  The 
operation  of  opening  the  trachea 
through  an  external  surgical 
wound  in  the  neck. 

Tract.  A  definite  group  of  nerve- 
fibres  in  the  spinal  cord.  Also,  a 
group  of  organs  having  a  common 
or  allied  fimction:  urinaiy,  etc. 

Transfusion.   (See  under  Blood.) 

Transmission.  The  transfer  of  a 
disease. 

Transplant.  Grafting,  the  insertion 
of  a  part  of  tissue  or  organ  into 
the  same  or  a  different  individual 
to  supply  a  deficiency. 

Trauma.    Injury. 

Tremor.  A  trembling  or  shaking  of 
a  part. 

Trephine.  An  instrument  for  mak- 
ingacircular  opening  in  the  skull. 

Trifacial  nerve.  (See  Anatomy  and 
p.  127.)  The  fifth  cranial  nerve 
sensory  to  the  face,  so  caUed  from 
its  three  branches. 


Trional.  (See  Pharmacology.)  A 
hypnotic  drug;  dose  gr.  v  to  x. 

Trocar.  A  sharp  hoUow  needle,  for 
perforating  the  wall  of  a  cavity 
and  removing  fluid. 

Trochanter.  (SeeAnatomy.)  Abony 
prominence  at  the  upper  end  of 
the  femur. 

Truss.  (See  p.  163.)  An  apparatus 
used  to  cover  a  hernial  opening 
and  prevent  the  protrusion  of  the 
contents  of  the  sac. 

Tube.  Any  hollow  cylindrical  struct- 
ure.   AJnatomical,  fallopian  tubes, 
eustachian  tube,  etc. 
Pus  tubes,  chronic   inflamma- 
tion of  the  oviducts. 
Drainage  tubes,  composed  of 
glass  or  rubber. 

Tubercle.  A  small  nodule;  patho- 
logically, a  mass  composed  of 
cormective  tissue  and  giant  cells, 
caused  by  the  tubercle  bacillus 
and  characteristic  of  tuberculosis. 

Tuberculin.  An  extract  prepared 
from  special  cultures  of  the  B. 
tubercle,  used  in  the  diagnosis 
and    treatment    of    tuberculosis. 

Tumor.  (See  p.  40.)  A  swelhng,  usual- 
ly limited  to  new-growths. 

Turbinectomy.    The  removal  of  the     ,  / 
turbinate   bones   projecting   into 
the  nasal  passages. 

Turpentine.  (See  Pharmacology.) 
A  volatile  hydrocarbon,  derived 
from  certain  pines,  used  exter- 
nally in  emulsion  as  a  Hniment 
and  counter-irritant,  also  in  en- 
ema to  stimulate  intestinal  peri- 
stalsis and  expulsion  of  flatus. 

Tjrmpanites.  Distention  of  the  ab- 
domen caused  by  the  accumu- 
lation of  gas  in  the  intestine. 

Tympanitic.  Resonant  on  percus- 
sion; containing  air. 

Typhoid.  (See  Medicine  and  p.  33.) 
A  specific  infectious  fever  caused 
by  the  typhoid  bacillus. 

U 
Ulcer.  (See  p.  21.)  An  inflammatory 
process  involving  one  of  the  sur- 
faces of  the  body  or  the  lining  of  a 
cavity,  characterized  by  a  superfi- 
cial infection  and  loss  of  tissue. 


GLOSSAKY 


253 


Ulnar.  Pertaining  to  the  ulna  and 
the  inner,  httle-finger  side  of  the 
forearm. 

Umbilicus.  The  navel,  the  remains 
of  the  fetal  attachment  of  the 
umbilical  cord,  containing  the 
blood-vessels  important  in  the 
fetal  circulation.  (See  Physiology 
and  Embryology.) 

Urachus.  (See  Anatomy  and  Em- 
bryology.) A  fold  of  peritoneiun 
extending  from  the  fundus  of  the 
bladder  to  the  umbihcus,  repre- 
senting the  remains  of  an  impor- 
tant embryological  commimica- 
tion  with  the  bladder. 

Urea.  (See  Physiology.)  One  of  the 
'chief  nitrogenous  compounds  of 
the  urine. 

Ureter.  (See  Anatomy  and  p.  214.) 
The  duct  extending  from  the 
kidney  pelvis  to  the  bladder. 

Urethra.  (See  Anatomy  and  p. 
219.)  The  canal  extending  from 
the  bladder  to  the  surface  of  the 
body  at  the  urinary  meatus. 

Uric  acid  and  Urates.  Important 
substances  derived  from  the  body 
metabolism  and  excreted  in  the 
m-ine,  normally  in  solution. 

Urinary.  Pertaining  to  the  urine, 
also  to  the  organs  concerned  in 
the  secretion  and  elimination  of 
the  urine. 

Urogenital.  (See  under  Genito- 
urinary.) 

Urotropin.  (See  Pharmacology.)  A 
proprietary  preparation  of  hex- 
amethylenamine. 

Uterine.  Pertaining  to  the  uterus. 
(See  Anatomy,) 


Vaccine.  (See  special  works  and  p. 
16.)  A  substance  representing 
the  inactive  agent  of  an  infec- 
tious process,  killed  bacteria, 
injected  to  coiifer  immunity  or  to 
increase  the  resistance  to  the 
specific  infection. 

Vagina.  (See  Anatomy.)  The  canal 
extending  from  the  cervix  of  the 
uterus  to  the  external  genital 
opening,  the  vulva. 


Vagus.  (See  Anatomy  and  p.  113.) 
The  tenth  cranial  nerve,  or  pneu- 
mogastric. 

Valve.  A  membranous  fold  pro- 
jecting into  the  lumen  of  a  canal, 
and  permitting  the  movement  of 
contents  in  only  one  direction. 

Varicocele.  A  mass  of  dilated  and 
tortuous  blood-vessels,  veins. 

Varicose.  (See  p.  96.)  Dilated  and 
tortuous  vessels,  usually  veins. 

Vas.  A  vessel  or  duct. 

V.  deferens,  the  excretory  duct 
from  the  testicle. 

Vase-.  Pertaining  to  the  blood- 
vessels and  vascular  system. 
Vasomotor,  the  nerve-centre 
controlling  dilatation  and 
constriction  of  the  arteries, 
and  influencing  blood -pres- 
sure. 

Venereal.  Pertaining  to  or  due  to 
sexual  intercourse. 

Venesection.  Opening  a  vein;  bleed- 
mg. 

Ventral.  Anterior  or  front  part  of  a 
body  or  structure. 

Ventricle.  (  See  Anatomy.)  A  small 
cavity. 

Vermiform.   A  worm-like  structure. 
V.  appendix  (see  Anatomy  and 
p.  192.) 

Veronal.  (See  Pharmacology.)  A 
hj'pnotic  drug;  dose  gr.  v  to  x. 

Vertebral.  Pertaining  to  the  verte- 
bra and  spinal  column. 

Vesicle.  A  sac  contaming  fluids; 
vesical,  pertaining  to  such  a  sac. 
Example:  the  bladder. 

Viscus.    An  organ. 

Visceral.  Pertaining  or  relating  to 
an  organ. 

Volxmtary.  Under  the  direct  con- 
trol of  the  will.    ■ 

Volvulus.  (See  p.  180.)  A  twisting 
of  a  part  of  the  intestine  in  such  a 
manner  as  to  occlude  its  lumen 
and  cut  off  the  blood-supply. 

Vomit.  To  expel  material  from  the 
stomach  by  way  of  the  mouth. 

Vulva.  (See  Anatomy.)  The  exter- 
nal genital  opening  in  the  fe- 
male. 


254 


GLOSSARY 


W 
Wart.      An   outgrowth    from    the 

epithehum  of  the  skin. 

Wassermann    test.       (See    special 

works.)     A     specific     blood-test 

used  in  the  diagnosis  of  syphilis. 

Wen.     (See  p.  117.)     A  sebaceous 

cyst  in  the  scalp. 
"Wound.    (See  p.  49.)   A  solution  of 
continuity  of  a  tissue  or  structiu-e, 
usually  involving  the  skin. 
Wrist.     The  junction  of  the  hand 
and  forearm. 

Wrist-drop,  a  characteristic 
deformity  due  to  paralysis  of 
the  extensor  muscles  of  the 
hand,  from  injury  or  disease 
of  the  radial  or  micsculo- 
spiral  nerve. 


X-ray.     The    Rontgen   ray.      (See 

special  works.) 
Xiphoid.      The   lower   end   of   the 

sternum.    (See  Anatomy.) 


Yeast.  A  species  of  vegetable  par- 
asite, non-pathogenic. 

Yucca-wood.  Material  used  to 
make  sphnts. 


Zinc-oxide.  (See  Pharmacology.) 
An  amorphous,  antiseptic  powder, 
used  also  in  ointment  and  in  the 
composition  of  adhesive  plaster. 

Zygoma.  (See  Anatomy.)  The  bony 
arch,  above  the  cheek. 


INDEX 


Abdomen,  159 
distention  of,  181 
lesions  of,  159 
relaxation  of,  160 
wounds  of,  160 
Abducens  nerve,  113 
Abduction,  223 
Abortion,  223 
Abscess,  19 
cold,  19 
brain,   108 
liver,  199 
peri-rectal,  189 
spleen,  206 
stitch,  6,  49 
Accidental  wounds,  50 
Acid,  223 
boracic,  4 
carbolic,  4,  53 
Acne,  223 
Actinomyces,  37 
Acute  infections,  13 

sepsis,  30 
Adam's  apple,  140 
Addison's  disease,  223 
Adduction,  223 
Adenoids,  137 
Adenoma,  46 
Adhesions,  223 
Adolescence,  223 
Adrenalin,  56 
Adrenal  gland,  223 
Aerobic  bacteria,  2 
After-care,  operative,  61 
Agar-agar,  224 
Air  hunger,  224 

Alcohol,  injection  for  neuralgia,  128 
Alimentary  tract,  224 
Alkali,  224 
Alveolar  process,  134' 
Ambulant,  224 
Amoebic,  224 
Ampula  of  Vater,  200 
Amputation,  27 

spontaneous,  27 
Anaerobic  bacteria,  2 
Anaesthesia,  60 
Analgesia,  224 


Anaphylaxis,  224 
general,  67 
in  fractures,  80 
local,  69 

preparation  for,  60 
Anastomoses,  224 
Anemia,  224 
Aneurism,  94 
Angioma,  48 
Angiosarcoma,  48 
Ankle,  224 

Anomaly  of  ureter,  214 
Anorexia,  224 
Anterior  horn  cells,  100 
Anthrax,  224 
Antitoxine,  17 
Antiseptic,  4 

Antrum  of  Highmore,  131 
Anuria,  216 
Anus,  188 

Aorta,  lesions  of,  153 
Aperient,  224 
Aphasia,  225 
Aponeurosis,  225 
Apoplexy,  108 
Appendectomy,  195 
Appendicitis,  193 

chronic,  195 
Appendix  epiploicse,  186 
Appendix,  vermiform,  191 
Apposition,  225 
Arachnoid  membrane,  103 
Areola,  154 
Argyol,  225 
Aristol,  225 
Arm,  225 

arterial  system,  92 
Arsenic  in  syphihs,  39 
Arterial  hemorrhage,  54 
Arterio-venous,  225 
Articulations,  89 
Ascites,  167,  199 
Aseptic,  4 

wounds,  49 
Asphyxia,  225 
Aspiration,  joints,  90 

pleura,  153 
Association  areas,  99 

255 


256 


INDEX 


Asthma,  225 
Ataxia,  225 
Athyroidism,  143 
Atrophy,  225 
Auditory  nerve,  113 

canal,  120 
Autogenous  vaccines,  16 
Autopsy,  225 
AxUla,  225 

B 

Bacteria,  1 

Baking  sterilization,  4 

Banti's  disease,  206 

Barium  in  X-ray,  226 

Barthohn's  glands,  226 

Base  of  skull,  fractin-e,  116-118 

Basedow's  disease,  145 

Bed-sores,  226 

Belladonna,  226 

Benzine  iodine  cleansing,  59 

Benzoates,  226 

Bile  passages,  202 

lesions  of,  202 
Bile  pigments,  200 
Birth,  226 

Bismuth,  gastric  ulcer,  178 
Bites  of  animals,  53 
Bladder,  215 

fimctional  disturbances,  216 

injury  of,  fracture,  pelvis,  86 

lesions  of,  218 
Bleeders,  55 
Blindness,  124 
Blood  count,  13 

composition,  226 

cultures,  31 

serum  in  hemorrhage  56 

transfusion,  56 
Body,  in  relation  to  bacteria,  5 
Boihng,  steriUzation,  4 
Bones,  classification,  71 

lesions  of,  74 

structure  of,  71 

tumors  of,  77 
Boracic  acid,  4 
Bougie,  227 

Brachial  plexus,  113,  14 
Bradycardia,  106 
Brain,  105 

abscess  of,  108 

lesions  of,  106 
Breast,  154,  156 
Broken  compensation,  167,  227 


Broncho-pneumonia,  67 

Bubo,  227 

Bunion,  227 

Burns,  28 

Bursa,  91 

Button,  Murphy,  227 


Calculi,  renal,  213 

bihary,  203 
Callus,  227 
Cancellous  bone,  73 
Cancer,  46 

appendix,  196 

bladder,  219 

gaU-bladder,  204 

of  intestine,  188 

of  Uver,  200 

of  rectmn,  191 

of  stomach,  179 
Canker,  228 

Capillary  hemorrhage,  54 
Capsule,  new-growth,  42 
Caput  succedaneum,  228 

joint,  89 
Carbuncle,  117 
Cardiac,  228 
Caries,  228 
Carron  oil,  28 
Carotid  artery,  141,  148 
Carpal  bones,  86 
Carrel-Dakin  technique,  51 
Cartilage,  epiphyseal,  71 
Caruncle,  220 
Casts,  plaster  of  paris,  81 
Cataract,  126 
Catharsis,  in  appendicitis,  194 

before  operation,  60 

in  indigestion,  173 

in  peritonitis,  169 
Catheterization,  208 

urethra,  217 

ureter,  211 
Cautery,  228 
Cecum,  192 
Cehac,  228 
Celiotomy,  228 
CelluUtis,  10 

Central  nervous  system,  101 
Cerebro-spinal  canal,   102 

fluid,  103 
Cerebral  cortex,  99 
Cerumen,  120 


INDEX 


257 


Cervical  region,  140 

rib,  149 
Chancre,  38 

of  lip,  133 
Change  of  hfe,  229 
Cheek,  126 

Chemical  germicides,  4 
Chills,  13 

Chloroform  anaesthesia,  68 
Cholsemia,  202 
Cholecystectomy,  204 
Cholecystitis,  202 
Cholecystostomy,  204 
Cholehthiasis,  203 
Cholestrin,  200 
Chondroma,  47 
Chronic  sepsis,  12 

infections,  30 
Circulation,  229 

co-lateral,  26,  92 

portal,  167,  198 
Cirrhosis  of  liver,  198 
Classification,  bacteria,  1 

tumors,  41 

woimds,  50 
Clavicle,  fracture,  84 
Clean  wounds,  49 
Cleft  palate,  135 
Chmacteric,  229 
Clinic,  229 
Clonic,  229 
Closed  fractures,  78 

woimds,  49 
Clot,  229 

Coagulation,  time,  55 
Coaptation,  229 
Cocaine,  local  anaesthesia,  69 
Coffee  in  shock,  64,  196 
Colic,  gaU-stone,  appendiceal,  204 

ureteral  213 
Cohtis,  187 
Collapse,  230 
CoUes'  fracture,  86 
Colon,  186 
Colon  bacUli,  34 
Colony,  230 
Colostomy,  187 
Coma,  230 

Comminuted  fracture,  78 
Common  bile  duct,  200 
Compensatory,  230 
Compound  fracture,  78 
Conception,  230 
Concealed  hemorrhage,  55 
X7 


Concussion  of  brain,  106 
Confinement,  230 
Congenital,  230 
Congestion,  230 
Conjunctivitis,  124 

gonorrheal,  33 
Constipation,  182,  230 
Constitutional,  230 

effects  of  sepsis,  13,  30 
Contagious,  230 
Contamination,  230 
Contraction,  cicatricial,  24 
Contused  wounds,  50 
Contusion  of  brain,  107 
Contraindications,  to  ansesthetic,  63 

to  operation,  57 
Convulsions,  230 
Corneal  ulcer,  124 
Corrosive  subhmate,  53 
Coryza,  130 
Cradle,  231 
Cramp,  231 
Cranial  nerves,  112 
Craniotomy,  109 
Cranium,  116 
Crepitus,  79 
Cretinism,  143 
Cricoid  cartilage,  145 
Crisis,  13,  30 
Croup,  membranous,  146 
Cultures,  1,  13,  31 
Cupping,  231 
Cyanosis,  231 
Cystic  duct,  200 
Cyst  of  pancreas,  205 
Cystitis,  218 
Cystoscopy,  218 
Cystotomy,  218 

D 

Dakin-Carrel  technique,  51 
Decompression,  cerebral,  109 
Decubitus,  231 
Deformity,  fractures,  90 
Degeneration,  malignant,  24,  42 

demarcation  fine  of,  27 

of  nerve  fibres,  99 

reaction  of,  113 
Deluimn,  231 
Dendrites,  98 
Dermoids,  40,  231 
Diabetes,  231 
Diagnosis,  fractures,  70 

nature  of  infection,  30 


258 


INDEX 


Diaphragm,  231 
Diaphysis,  71 
Diarrhoea,  232 
Diet  ia  gastric  ulcer,  178 
Differential  blood  count,  13 
Dilatation  of  stomach,  65,  176 
Diphtheria,  232 
Dirty  wounds,  49 
Dislocation  of  joints,  90 
Distention  of  abdomen,  181 
Distribution  of  bacteria,  3 
Diuresis,  232 

DiverticuHtis,  of  colon,  188 
Dog  bites,  63 
Dorsum,  232 
Douche,  232 
Dramage,   15,  30,  232 
Drum,  ear,  120 

rupture  of,  122 
Duct,  232 
Duodenum,  184 
lesions  of,  185 
Dysmenorrhoea,  232 
Dyspncea,  232 
Dysuria,  232 

E 

Ear,  122 

lesions  of,  124 
Ecchymosis,  54,  232 

in  fractures,  79 
Ectoderm,  232 
Ectopic,  232 
Eczema,  232 
Edema,  232 
Efferent  nerves,  99 
Effusion,  in  joints,  89 

pleural,  153 
Elbow,  fractures  of,  85 
Elective  operations,  57 
Electrolysis,  232 
Elimination  of  toxines,  15 
Embryo,  232 
Embryonic    development    of 

tumors,  40 
Emergency  operation,  57 
Emesis,  232 
Empyema,  153 
Encapsulation,  10 
Enema,  Nobles',  232 

nutritive,  63 

oil  and  glycerin  in  intestinal 
obstruction,  184 
Enterostomy,  183 


Entry,  portal  of,  7 
Enucleate,  232 
Enuresis,  232 
Epigastric  region,  159 
Epilepsy,  233 
Epiphysis,  71 
Epistaxis,  132 
Epithehal  tumors,  45 
Epithelioma  of  lip,  133 
Epithehima,    types    of,  5 

in  relation  to  bacteria,  6 
Epulis,  233 

Eseria  in  iatestiual  obstruction,  184 
Ether  anaesthesia,  68 
Ethmoidal  sinus,  132 
Ethyl  chloride,  233 
Eustachian  tube,  121 
Excision  foci  of  infection,  15,  30 
Excreta,  233 
Exophthalmic  goiter,  145 
Expectant,  233 
Exploratory,  233 
Extravasation,  233 
Exudate,  233 
Eyes,  lesions  of,  123 


Face,  123 

Facet,  233 

Facial  nerve,  paralysis,  113,  127 

Fades,  233 

Fallopian  tube,  234 

Farcy,  234 

Fascia,  234 

Fauces,  137 

Feces,  234 

Fecoliths,  192 

Feeding,  before  operation,  60 

after  operation,  62 

gastric  ulcer,  178 

peritonitis,  169 
Femoral  hernia,  165 
Femur,  fracture  of,  87 
Fetus,  234 
Fever,  inflammation,  12 

post-operative,  66 
Fibroid,  48 

Fibula,  fracture  of,  88 
First  aid,  fractures,  81 

wounds,  51,  52 
First  intent  healing,  50 
Fissure  in  ano,  189 

of  lip,  133 

of  nipple,  155 


INDEX 


259 


Fistula,  20 

congenital,  20 

fecal,  196 

in  ano,  189 

necrotic,  20 

of  colon,  187 

therapeutic,  21 

tramnatic,  20 
Flat  bones,  73 
Flatus,  234 
Flexion,  234 
Flexures  of  colon,  186 
Fluctuation,  10,  234 
Fluoroscope,  234 
Focus,  234 
FoUicle,  234 
Fomentation,  234 
Fontanelle,  234 
Foramen,  234 
Forceps,  234 
Formaldehyde,  234 
Fossa,  234 
Fracture,  complications,  79 

evidences,  79 

spontaneous,  77 

treatment,  80 

types,  78 
Fracture,  pelvis,  86 

skull,  106,  118 
Freezing,  27 
Frenum,  234 
Frontal,  234 
Forehead,  123 
Fukninating,  234 
Fumigation,  235 
Functional,  235 
Furuncle,  120 

G 

Gag,  235 
GaH-bkdder,  200 
cancer  of,204 
Gall-stones,  203 
GangUon,  235 
Gangrene,  25 

Gas  bacillus,  infections,  35 
Gas  pains,  65 
Gasserian  ganglion,  128 
Gastric  cancer,  179 
Gastric  ulcer,  177 
Gastro-enterostomy,  175 
Gastro-intestrnal  tract,  172 
Gdvage,  235 
Germicides,  4 


Gestation,  235 

Giant-cell  sarcoma,  48 
Glanders,  235 
Glioma,  48 

Glosso-phary-ngeal   nerve,    113 
Glottis,  oedema  of,  146 
Gloves,  use  of,  6 
Goiters,  144 

Gonococcus  infections,  32 
Gram's  stain,  236 
Granulations,  23 
Graves'  disease,  145 
Gravel,  236 

Greenstick  fractures,  78 
Grey  matter,  spiual  cord,  100 
Groin,  236 
Gumma,  38 

of  hver,  200 
Gums,  lesions  of,  134 
Gynecology,  236 

H 

Haematemesis,  177 
Hsematocele,  55 
Hsematoma,  54 
Hsematuria,  209,  214 
Haemoptysis,  236 
HgemophUia,  236 
Hanging  drop,  236 
Hare-lip,  133 
Haversian  canal,  236 
Head,  116 
Heahng,  fracture,  80 

wound,  50 
Heart,  lesions,  154 
Heat,  sterihzation  bj-,  4 
Hectic,  236 
Hemorrhage,  52 

concealed,  54 

control  of,  52 

gastric,  176 

intra-cranial,  107 

open,  53 

post-operative,  64 
Hemorrhagic  pancreatitis,  205 
Hemorrhoids,  189 
Hemostat,?236 
Hepatic  duct,  201 
Hereditary,  236 
Hernia,  162 
Heroin,  236 
Herpes,  236 
Hexamethylene,  211 
Hiccough,  236 


260 


INDEX 


Highmore,  antrum  of,  131 
Hilum  of  kidney,  207 
Hip,  237 

Hodgkin's  disease,  143 
Home,  operations  at,  56 
Horseshoe  Iddney,  207 
Hour-glass  stomach,  175 
Housemaid's  knee,  91 
Hiunerus,  fracture  of,  84 
Hunger  pain,  177 
Hyahne,  237 
Hydrocele,  237 
Hydrocephalus,   103 
Hydronephrosis,  208,  211 
Hydrophobia,  237 
Hygiene,  237 
Hyperacidity,  176 
Hjrpernephroma,  214    • 
Hyperthyroidism,  144 
Hypnotic,  237 
Hypochlorite  of  lime,  51 
Hypochondriac  region,  159 
Hypodermoclysis,  56 
Hypogastric,  159 
Hypoglossal  nerve,  113 
Hysterectomy,  237 


Ichthyol,  237 
Iliac  region,  159 
Ileus,  180 
Ileum,  184 

Immobilization,  fractures,  81 
Immunity  to  infection,  8 
Impaction,  237 
Imperforate  anus,  188 
Implantation,  237 
Incarceration  of  hernia,  162 
Incised  wounds,  50 
Incision,  30 

Incontinence,  urine,  216 
Incubation,  period  of,  238 
Indigestion,  acute,  172 

chronic,  173 
Individual  protection,  8 
Infarction,  238 
Infected  wounds,  49 
Infections,  31,  9 
Infiltration,  238 

anaesthesia,  69 
Inflammation,  7 
Influenza,  238 
Infractions,  78 
Inguinal  hernia,  165 


Injections,  238 

Innocent  tumors,  42 

Inoculation,  animal,  31 

Intestinal  obstruction,  180 
hernia,  163 
post-operative,  66 
tract,  180 

Intoxications,  238 

Intracranial  hemorrhage,  107 
pressure,  106 

Intravenous,  62 

Intussusception,  180 

Intubation,  146 

Inunction,  238 

Involucrum,  74 

Involuntary,  238 

Iodine-benzine  mixture,  59 

Iodine  tincture,  4 

Iodoform,  238 

Iris,  239 

Irregular  bones,  73 

Ischio-rectal  space,  239 

Ischium,  239 


Jacksonian  epilepsy,  106 
Jaundice,  200 

cause  of  hemorrhage,  55 
Jaw,  lower,  lesions  of,  138 
Jejunum,  185 
Joint-mice,  91 
Jugular  veins,  lesions  of,  140 

K 

Keloid,  239 

Kidney,  207 
abscess  of,  209 
malformations  of,  209 

ICnee-cap,  fracture  of,  87 

Kyphosis,  75,  150 

L 

Lacerated  wounds,  50 
Lacerations,  239 
Laparotomy,  161 
Laryngo-pharynx,  137 
Larynx,  145 
Lavage,  gastric,  59 
Leg,  fractures  of,  88 
Leucocytosis,  13 
Leukemia,  239 
Levator  ani  muscle,  239 
Ligament,  239 
Ligation  of  vessels,  91 
effects  of,  93 


INDEX 


261 


Ligature,  239 

Lime,  hypochlorite  of,  51 

salts,  ia  hemorrhage,  56 
Linea  alba,  159 
Lingual,  239 
Liniment,  239 
Lipoma,  47 
Lips,  133 
Liquor,  239 
Lithiasis,  240 
Lithotomy,  240 
Liver,  abscess,  194 

anatomy  of,  198 

lesions  of,  199 
Local  anaesthesia,  69 
Longitudinal  bands  of  colon,  186 
Loose  bodies  in  joints,  91 
Lordosis,  75 

Lower  segment  neurones,  101 
Lues,  240 
Lumbar  puncture,  105,  240 

region,  159 
Lungs,  lesions  of,  151 
Lutein,  38 
Lymph,   12 

Ljrmphatics,  system,  96 
Lymph-nodes,  infections,  97 

mahgnant,  97 
Lymphocytes,  12 
Lysis,  240 
Lysol,  4 

M 

Maceration,  240 
Major  operations,  56 
Malaise,   240 
Malaria,  240 
Malformations,  bladder,  219 

breast,  156 

colon,  186 

kidney,  207 

nipple,  155 

rectmn,  188 

stomach,  174 
MaUngerer,  240 
Mahgnant  cedema,  35 

new-growths,  43 
Malleolus,  fracture  of,  88 
Mammary  gland,  154 
Mandibular,  240 
Manure,  3 
Marrow  bone,  74 
Mastitis,   150 
Mastoid,  120 


McDonald's  solution,  59 
Meatus,  241 
Mediastinum,  154 
MeduUa  oblongata,  105 
Melano-sarcoma,  48,  124 
Membrane  bones,  73 
Meninges,  101 

lesions  of,  102 
Meningitis,   108 
Meningocele,  117 
Menopause,  241 
Menorrhagia,  241 
Mercury,  in  sj^philis,  39 

antiseptic  preparations,  4 
Mesentery,   160 
Mesoderm,  241 
Metabohsm,  241 
Metacarpal  bones,  86 
Metamorphosis,  241, 
Metastasis,  43 
Metatarsal  fractures,  88 
Meteorism,  241 
Metritis,  241 
Metrorrhagia,  241 
Microscopic  structure  of  tumors,  45 
Middle  ear,  121 
Milk-leg,  95 
Minor  operation,  56 
Miscarriage,  241 
Mixed-cell  sarcoma,  48 
Moles,  48,  241 
Montgomery's  glands,  155 
Morphine,  before  anaesthesia,  60 
appendicitis,  194 
peritonitis,  169 
urinary  calculi,  219 
Morbidity,  241 
Motor  areas  of  brain,  99 
Mouth,  care  of  before  anaesthesia, 60 

lesions,  133 
Mucous  membranes,  6 

patches,  38 
Mumps,  129 
Mural  timiors,  45 
Murmurs,  241    , 
Muscle,   spasm,   241 
Musculo-spiral  nerve  paralysis,  85 
Myelogenous  leukemia,  206 
Myoma,  47 
Myxedema,  143 

N 
Narcosis,  242 
Nasal  septum,  132 


262 


INDEX 


Naso-pharynx,  137 

Nausea,  post-operative,  65 

Neck,  140 

Necrotic,  10 

Neoplasm,  242 

Neo-salvarsan,  242 

Nephrectomy,  242 

Neuroma,  48 

Nerve  trimk,  injury,  fracture,  79,  82 

Nervous  system,  98 

Neurone,  98 

Neuralgia,  242 

Nevus,  242 

New-growths,  40 

Nipple,  154 

Nitrous  oxide  anaesthesia,  68 

Nobles'  enema,  243 

Noguchi's  test,  243 

Noma,  243 

Non-pathogenic  bacteria,  2 

Non-union  of  fractures,  83 

Normal  saline,  243 

Nose  lesions,  129 

bleed,  132 
Novocaine  anaesthesia,  69 

O 

Obstetrics,  243 
Obstipation,  243 
Obstruction,  intestinal,  181 
Occlusion  of  intestine,  180 

of  ureter,  215 

of  vessels,  93 
Occult  blood,  177 
Oculo-motor  nerve,  112 
(Esophagus,  148 
Olfactory  nerve,  112 
Omentum,  166 
Open  fractures,  78 

treatment,  fractures,  82 
Operations,  56 
Ophthalmia  neanatorum,  33 

sympathetic,  124 
Ophthalmoscope,  243 
Opisthotonus,  243 
Opsinins,  243 
Optic  nerve,  112 
Orbit,  125 

lesions  of,  126 
Organic,  243 
Orifice,  243 
Oropharyrix,  137 
Orthopedics,  243 
Ossicles,  ear,  121 


Ossification  centres,  71 
Osteitis,  74 
Osteoblasts,  73 
Osteoclast,  243 
Osteomyelitis,  74 
Otitis  media,  122    . 
Ovary,  244 
Ovum,  244 
Oxalates,  244 


Pack,  244 

Pain,  fractures,  79,  81, 

post-operative,  62,  64 
Pajet's  disease,  breast,  155 
Palate,  135 
Palpation,  244 
Pancreas,  205 
Pancreatitis,  205 
Papilloma,  bladder,  219 
Papules,  11 
Paracentesis,  244 
Paraffin,  in  burns,  29 
Parasites  in  new-growths,  40 

vegetable,  37 
Parathyroid  glands,  244 
Parenchyma,  244 
Parotid  gland,  128 
Parotitis,  129 
Parturition,  244 
Paste,  bismuth,  244 
Pasteur  treatment,  53,  244 
Patella,  fracture  of,  87 
Pathogenic  bacteria,  2 
Pathology,  244 
Pedimculated  tumors,  45 
Pelvis,  fracture,  86 

of  kidney,  207 
Perforation,  gastric  ulcer,  178 
Pericardium,  154, 
Perinephritic  abscess,  194 
Perineum,  245 
Periosteum,  73 
Periostitis,  75 
Peripheral  nerves,  113 
Peritoneum,  165 
Peritonitis,  appendicitis,  193 

post-operative,  66 
Perirectal  abscess,  189 
Peritonsillar  abscess,  137 
Per  primam,  healing  by,  50 
Pessary,  245 
Petit  mal,  106 
Payer's  patches,  185 


INDEX 


263 


Phagocytes,  10 

Phalanges,  fracture  of,  86 

Pharynx,  137 

Phlebitis,  95 

Phlebotomy,  95 

Phlegmasia  alba  dolens,  95 

Pia  mater,  245 

Piles,  190 

Pillow  splint,  81 

Pitcher  douche,  217 

Pituitary  body,  109 

Pituitrin,  56,  184 

Plasma  cell,   10 

Plaster  of  paris  splints,  81 

Pleural  cavity,  151 

Pleurisy,  153 

Plexus,  brachial,  113,  141 

Pnevunogastric  nerve,   113,  141 

Pneumococcus,  33 

Pnemno  thorax,  151 

Pneumonia,  post-operative,  67 

Phlegmon,  245 

Phthisis,  245 

Polj^s,  45 

Portal  circulation,  198 

of  entry,  7 
Positions,  post-operative,  61 
Post-operative  care,  61 

compUcations,  63 

hernia,  164 
Poupart's  hgament,  246 
Potassimn  iodide,  39 
Pott's  disease,  75 

fracture,  88 
Premaxillary  bone,  135 
Preparations  for  operation,  58 

for  anaesthesia,  63 
Proctoclysis,  62 
Proctoscope,  246 
Prodrome,  246 
Projection  cells,  99 
Prolapse,  246 
Prophylaxis,  246 
Prostate  gland,  220 
Proud  flesh,  23 
Pruritus,  202 
Psoas  abscess,  75 
Puberty,  247 
Puerperium,  247 
Pulse,  248 
Pupil,  248 
Purulent,  248 
Pus,  10 
Pustules,  11 


Putrefaction,  248 
Ptomaines,  indigestion,  172 
Pyemia,  14 
Pyloroplasty,  175 
Pylorus,  stenosis,  174 

stricture,  175 
Pyonephrosis,  211 
Pyorrhoea  alveolaris,  134 


Quinine,  247 
Quinsy,  137 


Q 


R 


Rabies,  53 

Radial  nerve  paralysis,  85 

Radiogram,  247 

Radium  in  nev/-growths,  44 

Radius,  fracture  of,  85 

Rachitis,  248 

Ranula,  137 

Rectum,  lesions  of,  188 

Rectus  muscle,  159 

Recurrence  of  new-growth,  43 

Reduction  of  fractures,  80 

Regeneration  nerve-fibres,  99 

Regurgitation,  247 

Renal,  247 

Repair  of  fractures,  80 
of  wounds,  50 

Resection,  247 

Residual  urine,  215 

Resistance  of  bacteria,  2 

Resolution,  10 

Retention  of  urine,  66,  215 

Retention  catheter,  218 

Retropharyngeal  abscess,  149 

Rheumatism,  248 

Rib,  cervical,  149 

Ribs,  lesions  of,  150 

Rigg's  disease,  248 

Rontgen  ray,  fractures,  80 
malignant  disease,  40 
urinary  calcuU,  213 

Root  abscess,  134 

Round-cell  sarcoma,  48 

Rudimentary,  248 

Rupture,  162 


S 


Sacro-iUac  joint,  248 
Saliva,  248 
Salol,  211 


264 


INDEX 


Salpingitis,  gonorrhcEal,  33 

Salvarsan,  39 

Sapremia,  248 

Sarcoma,  48 

Scab  formation,  23 

Scalp,  wounds,  116 

Sciatic,  248 

Sclerosis,  248 

Scoliosis,  75,  150 

Sebaceous  cysts,  248 

Secretion,  249 

Section,  248 

Sepsis,  9,  13 

Septic  -wounds,  49 

SepticEemia,  14 

Septum,  nasal,  sequestrum,  130,  174 

Sequelae,  248 

Serum  in  hemorrhage,  56 

Serums  in  infections,  16 

Sewage,  3 

Sessile  tumors,  45 

Shock,  63 

Silent  areas  of  brain,  99 

Sim's  position,  249 

Sinus,  accessory,  facial,  130 

infected,  10,  19 

venous,  101 
Skiagraphy,  249 
Skin  sterilization,  6 
Sloughing,  23 
Smears,  1 

Sodium  bicarb.,  in  gastric  ulcer,  178 
Solution,  McDonald's,  59 
Sounds,  249 
Speculum,  250 
Specific  resistance,  16 
Spermatic  cord,  250 
Sphenoidal  sinus,  132 
Spinal  accessory  nerve,  113 

anaesthesia,  69 

cord,  anatomj',  110 
lesions,  111 
Spirochseta  palhda,  37 
Spleen,  lesions,  205 
Splenic  anemia,  206 
Splints  for  fractures,  81 
Sponge,  250 
Spores,  2 
Sprains,  91 
Stains,  250 
Staphylococcus,  31 
Stasis,  250 

Stenosis  pylorus,  174 
Sterilization,  3 


Stemo-cleido-mastoid  mxiscle,  140 
Sternum,  151 
Stertorous  breathing,  250 
Stethoscope,  250 
Stock  vaccines,  17 
Stomach,  174 

dilatation  of,  65 
Stomatitis,  250 
Strangulated  hernia,  163 
Streptococcus,  infections,  31 
Stricture,  cicatricial,  24 

pjdorus,  175 
Strophanthin,  250 
Strychnine,  250 
Stupes,  ureteral  colic,  213 
Stupor,  250 
Subluxation,  250 
Submucous  tumors,  45 
Subserous  tumors,  45 
Supination,  251 
Suppository,  251 
Suppurating  appendicitis,  193 
Suppuration,  10 
SjTnphysis  pubes,  86 
Syncope,  251 
Syndrome,  251 
Synovial  membrane,  89 
Syphilis,  37 

bone,  76 
Syringe,  251 
Systemic,  251 


Tachycardia,  145 
Tampon,  251 

Tarsal  bones,  fracture,  88 
Technique,  antiseptic,  4 

aseptic,  4 
Tenesmus,  251 
Testicle,  251 
Tetanus,  infections,  34 
Tetany,  251 
Thorax,  150 
Throat,  137 
Thrombosis,  67,  95 
Th\Tnus,  154 
Thyroglossal  duct,  251 
Thyroid  gland  lesions,  143 
Tibia,  fracture  of,  88 
Tongue,  136,  252 
Tongue-tie,  136 
Tonsils,  137 
Tonsillitis,  137 
Tourni'.'iuet,  52 


INDEX 


265 


Toxaemia,  13 
Trachea,  146 
Tracheotomy,  147 
Tract,  252 

Transfusion  of  blood,  56,  94 
Transplant,  252 
Transportation  of  patients,  58 
Triangles  of  neck,  140 
Trifacial  nerv^e,    112 

neuralgia,  120 
Trocar,  252 
Trochanters,  252 
Trochlear  nei-ve,  120 
Truss  in  hernia,  163 
Tubercle  bacilh,  infections,  35 
Tubercuhn,  37 
Tuberculosis  of  bone,  75 
intestinal  tract,  185 
peritoneum,  170 
urinary  tract,  211 
Tumors,  45 
of  bone,  77 

of  brain,  kidney,  109,  214 
of  breast,  pancreas,  157,  205 
of  eye,  124 
Turbenectomy,  252 
Turbinate  bones,  130 
Turpentine,  252 
TjTnpanites,  180 
Tjonpanum,  127 
Typhoid  infections,  33 
ulcers,  185 

U 

Ulcers,  21 

duodenum,  185 

intestine,  185 

rectum,  188 

stomach,  176 
Ulna,  fracture  of,  85 
Umbilical  hernia,  164 

region,  159 
Upper  segment  neurones,  101 
Urachus,  253 

Urea  hydrochloride  anaesthesia,  69 
Ureter,  214 
Ureteral  colic,  212 
Urethra,  219 
Urethritis,  32,  219 
Urinary  antiseptics,  211 
Urine,  retention  of,  65 
Urotropin,  253 
Uvula,  135 


Vaccines,  16 
Vagina,  253 

Vaginitis,  gonorrhceal,  32 
Vagus  nerve,  113,  141 
Varicocele,  253 
Vas  deferens,  253 
Vascular  system,  92 
Vault  of  skull,  116 

fractures  of,  118 
Vegetable  parasites,  37 
Veins,  varicose,  95 
Venereal,  253 
Venesection,  253 
Venous  hemorrhage,  54 

sinuses,  101 
Ventricles  of  brain,  103 
Vertebral  lesions,  75,  148 
Vesicle,  253 
Vessels  of  neck,  140 
Virulence  of  bacteria,  2 
Vocal  cords,  146 
Volvulus,  180 
Vomiting,  intestinal  obstruction,  ISl 

post-operative,  65 
Vulva,  253 

W 

Warts,  254 

Wassermann  reaction,  38 
Vv-'ens,  117 
Windpipe,  146 
Wounds,  care  of,  49 

of  abdomen,  160 

of  bladder,  217 

of  mtestine,  185 

of  kidney,  209 

of  liver,  199 

of  scalp,  116 
Wrist  drop,  85 


X 


X-rays,  44,  80 
Xyphoid,  254 


Yeast,  254 


Zinc  oxide,  254 
Zygoma,  254 


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